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A    HANDBOOK    OF    FEVERS. 

J.  Campbell  McClure,  M.D. 


To  THE  Memory  of 
The     Late    SIR    WILLIAM    GAIRDNER,    K.C.B., 

AND 

The    Late    J.    B.    RUSSELL,    M.D., 

THE    TWO    FIRST    MeDICAL    OFFICERS    OF    HeALTH 

FOR  THE  City  of  Glasgow. 


A 

HANDBOOK  OF  FEVERS 


BY 

J.   CAMPBELL  MCCLURE, 

M.D.  (Glasgow). 

PHYSICIAN  TO  OUT-PATIENTS,  THE  FRENCH  HOSPITAL,  LONDON,  AND  PHYSICIAN  TO 

THE    MARGARET    STREET    HOSPITAL    FOR   CONSUMPTION    AND    DISEASES 

OF   THE   CHEST,    LONDON. 

FORMERLY— SENIOR      RESIDENT     ASSISTANT      PHYSICIAN,      ASSISTANT 

SUPERINTENDENT,    AND  RESIDENT  MEDICAL  OFFICER   IN 

CHARGE      OF     THE      SMALLPOX      HOSPITALi 

BELVIDERE    FEVER   HOSPITAL, 

GLASGOW. 


PAUL    B.     HOEBER, 

6  7-6  9,    EAST     59  th     STREET, 

NEW    YORK. 

19U. 


V 
'/fe  -    -  -^0  5 


LONDON  : 

Shaw  &  Sons,  Printers,  Fetter  Lane,  Fleet  Street,  E.G. 


V 


n 


\   '12.. 


PREFACE 


rpiHIS  book  pretends  to  be  no  more  than  a 
-^  handbook  for  the  use  of  students  and  general 
practitioners,  and  the  author  has  endeavoured  as  far 
as  possible  to  confine  his  attention  to  the  more 
practical  aspects  of  the  diseases  under  consideration, 
devoting  more  space  to  treatment  than  many  will 
perhaps  approve  of.  Detailed  descriptions  of  the 
pathological  anatomy  of  the  various  diseases  have 
been  purposely  avoided,  and  only  such  points  in 
epidemiology  and  bacteriology  have  been  dwelt  upon 
as  seem  to  be  absolutely  necessary.  Only  those 
tropical  diseases  have  been  included  in  this  small 
volume  as  may  possibly  be  met  with  in  Great  Britain 
in  the  ordinary  course  of  practice.  Beriberi  has  been 
included  since,  although  it  is  not  strictly  a  febrile 
disease,  it  appears  to  be  due  to  some  specific  infection, 
and  is  not  infrequently  seen  in  our  larger  seaport 
towns.  The  inclusion  of  a  chapter  on  Pellagra  has 
been  rendered  necessary  by  the  discovery  that  the 
disease  is  prevalent  in  the  United  States  of  America 
to  a  degree  undreamed  of  half  a  dozen  years  ago, 
and  by  the  fact  that  it  seems  likely  that  in  the  next 


vi  Preface. 

few  years  a  considerable  number  of  cases  will  be 
discovered  in  this  country.  The  disease  is  unknown 
to  the  majority  of  practitioners  in  the  British  Islands, 
and  it  is  probable  that  increased  knowledge  of  the 
symptomatology  and  course  of  this  interesting  disorder 
will,  as  was  the  case  in  the  summer  of  1913,  lead 
to  the  discovery  of  the  disease  in  areas  hitherto 
unsuspected. 


59,  Harley  Street,    W. 


CONTENTS. 


CHAPTER 


I.  Introductory 


PAGE 

1 


Fevers  of  Known  Bacteriology. 

II.  Enteric  Fever 

III.  Diphtheria     ... 

IV.  The  Plague 

V.  Cholera' 

VI.  Relapsing  Fever 

VII.  Malaria  

VIII.  Epidemic  Cerebro-Spinal  Meningitis 

IX.  Anthrax         ...  ...  

X.  Glanders 

XI.  Influenza 
XII.  Pulmonary  Tuberculosis     ... 

XIII.  Dysentery 

XIV.  Kala  Azar 


10 

47 

72 

84 

97 

105 

125 

137 

146 

154 

166 

194 

208 


viii  Contents. 

Fevers  of  Uncertain  Bacteriology. 

CHAPTER  PAGE 

XV.  Scarlet  Fever            216 

XVI.  Measles          252 

XVII.  German  Measles       274 

XVIIL  Small-pox     283 

XIX.  Chicken-pox              313 

XX.  Typhus          ..)         321 

XXI.  Mumps          347 

XXII.  Rheumatic  Fever 358 

XXIII.  Yellow  Fever           ... 379 

XXIV.  Whooping  Cough     395 


Acute  Diseases  frequently  attributed  to  a  Diet  consisting 
largely  of  certain  Cereals. 

XXV.  Beriberi         414 

XXVI.  Pellagra         ...         426 


Appendix  The  Serum  Treatment  of  Tuberculosis     ...         439 


Ceiapter  I. 


INTRODUCTORY. 

The  febrile  state,  to  whatever  cause  it  may  be  due,  is 
characterised  by  certain  general  signs  and  symptoms  which 
are  met  with  almost  constantly  whenever  there  is  any  con- 
siderable rise  of  temperature  above  the  normal.  The  patient 
may  at  the  onset  of  the  febrile  attack  experience  a  sense  of 
exaltation,  of  well-being  above  the  normal,  and  may  present  a 
facies  suggestion  of  mental  excitement  with  more  or  less 
flushing  of  the  cheeks  and  unusual  brightness  of  the  eye.  In 
other  cases  the  onset  of  fever  may  be  marked  by  a  sensation 
of  chill,  amounting  in  some  cases  to  an  undoubted  rigor,  with 
pallor  of  the  face  and  an  appearance  of  apprehension  and 
uneasiness.  In  any  case,  the  patient  is  soon  the 
subject  of  indefinite  malaise,  headache,  loss  of 
appetite  and  a  general  feeling  of  enfeeblement.  He  may  be 
quiet  and  drowsy,  or  restless  and  delirious.  He  feels  hot, 
complains  of  thirst,  may  suffer  from  nausea,  may  be  con- 
stipated, or  may  have  slight  diarrhoea.  The  face  is  flushed 
more  or  less  generally  according  to  the  disease,  the  eye  is 
usually  bright,  but  sometimes  dull  and  bloodshot,  and  there 
is  a  suggestion  of  "remoteness"  about  the  expression  of  the 
sick  person.  The  pulse  and  respiration  are  quickened,  in 
varying  proportion  to  the  rise  in  temperature  according  to  the 
disease  of  which  the  fever  is  a  manifestation.  The  urine  is 
scanty  and  high  coloured,  rich  in  urates  and  frequently 
deficient  in  chlorides.  It  is  usual  now-a-days  to  consider  that 
fever  is  the  effect  of  toxins  of  bacterial  origin  on  the  heat- 
regulating  mechanism,  so  that  there  is  at  the  same  time  an 
increase  in  heat  production,  the  result  of  increased  metabolic 
processes,  and  a  decrease  in  heat-loss,  due  to  the  poisoning  of 


2  Chapter  I. 

the  central  vasomotor  areas.  The  increase  in  the  rate  of 
respiration  is  probably  due  to  two  causes — (a)  an  attempt  to 
aerate  blood  unduly  charged  with  the  waste-products  of 
metabolism,  and  (b)  a  poisoning  of  the  respiratory  centres, 
while  the  increase  in  heart-rate  may  be  due  to  a  direct  in- 
hibition of  the  vagus,  or  stimulation  of  the  sympathetic 
cardiac  fibres  by  the  circulating  toxins. 

Fever  is  usuallj^  described  according  to  its  height,  and  also 
according  to  the  type  of  its  daily  variation.  A  temperature 
of  100°  F.  or  over  is  considered  to  be  febrile,  and  it  is  com- 
mon to  call  all  fever  over  105°  F.  liyyer'pyrexia.  In  febrile 
co7iditions  the  ordinary  daily  variation  of  temperature — slight 
morning  fall  and  evening  rise — is  usually  preserved.  In 
some  few  cases,  however,  the  evening  temperature  is  lower" 
than  the  normal,  and  it  is  possible  that  in  such  cases  this  has 
been  the  ordinary  habit  of  the  individual  in  health.  A  fever 
is  called  continued  when  the  daily  variation  is  only  two 
degrees  Fahrenheit  or  less.  It  is  called  reTnittent  when  the 
daily  variation  is  over  2°  F.  and  when  the  lowest  point  does 
not  fall  to  normal,  while  a  fever  which  has  a  daily 
variation  of  more  than  2°  F.  and  when  the  lowest  point  falls 
to  or  below  normal  is  called  intermittent. 

The  onset  of  a  fever  varies  greatly  in  different  cases. 
Sometimes  the  invasion  is  sudden  and  severe,  with  a  tempera- 
ture rising  to  high  pyretic  or  hyperpyretic  registers  in  a  few 
hours,  while  sometimes  the  invasion  is  slow  and  gradual — 
days  elapsing  before  the  fastigiuTn  or  height  of  the  fever  is 
reached.  Similarly  the  termination  of  the  fever  may  be 
sudden  and  complete  in  a  few  hours,  or  it  may  be  gradual, 
taking  seA^eral  days  to  reach  the  normal.  The  former  is 
called  termination  by  crisis,  the  latter  termination  by  lysis. 
Before  the  actual  complete  termination  of  a  fever,  a  fall  of 
the  temperature  to  normal,  or  nearly  so,  may  suddenly 
occur,  but  instead  of  remaining  in  normal  regions  the  tem- 
perature may  rise  again  as  suddenly  to  heights  as  great  or 
even  greater  than  before  the  fall.  Such  an  occurrence  is 
termed  a  yseudo-crisis. 

Accompanying  a  crisis  it  is  common  to  have  a  great  in- 
crease in  the  output  of  urine,  which  at  this  time  is  often  pale 


Introductory.  3 

and  may  contain  crystals  of  uric  acid.  Sweating  is  usually 
profuse,  and  there  may  be  a  tendency  to  diarrhoea.  These 
"critical  discharges"  have  been  observed  by  the  earliest 
writers  on  the  subject. 

In  estimating  the  temperature  of  a  patient  certain  pre- 
cautions must  be  observed.  A  reliable  thermometer  is  the 
j&rst  essential,  and  it  is  wise  to  have  an  instrument  furnished 
with  a  certificate  from  Kew  showing  the  actual  error  in  its 
registering.  The  thermometer  should  be  sensitive,  one  sup- 
posed to  register  the  temperature  accurately  in  30-60  seconds 
should  be  used,  but  it  should  be  kept  in  place  for  some  two 
minutes  before  reading.  The  temperature  of  the  axilla, 
groin,  mouth  or  rectum  may  be  taken,  and  it  must  be 
remembered  that  the'  skin  of  the  axilla  and  groin  should 
be  thoroughly  dried  before  the  thermometer  is  introduced. 
The  normal  temperature  is  considered  to  be  98.4°  F.  in  the 
axilla  or  groin,  98.8° — 99°  F.  in  the  mouth  or  rectum,  but 
considerable  phj^siologieal  variation  is  frequently  observed. 
Roughly  speaking,  a  temperature  of  97.4° — 98.8°  F.  in  the 
axilla  may  be  considered  normal;  above  that  to  100°  F.  it 
may  be_  described  as  subfebrile,  while  100°  F.  and  over  may 
be  reckoned  as  fehrile,  and  below  9T.4°  F.  anay  be  considered 
subnormal.  The  observer  should  remain  beside  the  patient 
while  the  thermometer  is  in  position  to  prevent  accidental 
moving  of  the  instrument,  or  manipulation  of  it  by 
malingerers  and  hysterical  patients. 

It  is  important  to  take  care  as  to  the  hours  at  which  the 
temperature  is  taken.  Where  fever  is  suspected,  it  is  not 
enough  to  take  a  usual  "morning  and  evening"  temperature, 
at  8  or  9  a.m.  and  8  or  9  p.m.  Where  only  two  readings  are 
taken,  the  maximum  temperature  is  often  missed  and  the 
physician  has  but  little  knowledge  of  the  daily  variation  in 
the  temperature-curve.  It  is  often  very-  difficult  in  practice 
to  have  accurate  observations  on  the  temperature  made  where 
no  trained  nurse  is  in  attendance,  but  in  these  days,  when  a 
clinical  thermometer  is  as  common  a  piece  of  furniture  as  a 
hot-water  bag,  it  is  not  usually  difficult  to  have  a  series  of 
fairly  dependable  observations  made  by  some  responsible 
member  of  the  household.  Among    the    poorer    and    less 


4  Chapter  J. 

educated  classes,  the  district  nurse  can  usually  be  relied  upon 
to  make  a  couple  of  calls  a  day  at  liours  which,  together  with 
visits  of  the  physician,  will  help  towards  a  reasonably  complete 
series  of  observations  of  the  temperature.  Regularity  in  the 
hours  of  taking  the  temperature  is  of  the  greatest  importance. 
Where  possible  the  temperature  should  be  observed  every 
four  hours,  4  a.m.,  8  a.m.,  12  noon,  4  p.m.,  8  p.m.,  and  12 
midnight,  or  tlie  liours  of  2  a.m.,  6  a.m.,  10  a.m.,  2  p.m.,  C 
p.m.,  and  10  p.m.  may  be  chosen.  The  early  morning  ob- 
servations at  2  a.m.  or  4  a.m.  may  be  omitted  if  circum- 
stances demand.  By  these  means  the  temperature  is  recorded 
at  the  same  time  each  day,  and  it  is  unlikely  that  any 
very  important  variation  will  be  missed.  In  certain  cases 
more  frequent  observations  may  be  necessary  or  at  least  ad- 
visable. In  cases  of  puhuonary  phthisis  who  do  not  require  to 
be  kept  in  bed,  it  is  necessary  to  observe  the  temperature 
before  and  after  exercise. 

There  are  certain  general  principles  which  underlie  the 
treatment  of  the  febrile  state  whatever  the  disease  be  in  which 
the  fever  is  a  symptom.  As  a  result  of  poisoning  by 
bacterial  toxins,  tissue  waste  is  abnormally  active,  and 
at  the  same  time,  the  powers  of  secretion  and  ex- 
cretion are  below  the  normal.  It  is  necessary  to  prevent,  and 
replace  as  far  as  may  be,  this  increased  wasting,  and  at  the 
same  time  to  increase  the  power  of  the  bactericidal  and  anti- 
toxic elements,  and  also  to  encourage  excretion  in  every 
possible  way.  Hest  in  bed  is  the  first  essential  during  the 
whole  period  of  fever,  and  for  such  time  after  as  the  con- 
dition of  the  patient  may  demand.  From  very  early  times  it 
has  been  recognised  clinically  that  rest  is  a  necessity  in  the 
treatment  of  the  acute  fevers,  and  it  is  interesting  to  note 
that  the  researches  of  Almroth  Wright  have  confirmed  this 
practice.  Wright  has  pointed  out  that  it  is  possible  in  cer- 
tain chronic  infective  processes  to  produce  by  movement  and 
exercise  a  toxaemia  which  is  beyond  the  immediate  capacity  of 
the  patient's  resisting  powers.  This  process  of  "auto-inocula- 
tion" may  be  used  for  curative  purposes  under  certain  condi- 
tions, but  the  realisation  of  the  meaning  of  the  process  will  make 
it  very  evident  that  the  production  of  an  "auto-inoculation" 


Introductory.  5 

by  movement  and  restlessness  on  the  part  of  a  patient 
acutely  ill  with  a  fever,  whose  powers  of  immunisation  are 
already  taxed  beyond  their  capacity  for  immediate  response, 
must  be  followed  by  evil  results  and  may  adversely  influence 
the  progress  of  the  disease.  Wright's  work  has  added  another 
reason  for  the  absolute  quiet  of  a  febrile  patient,  for  the 
necessity  of  procuring  sleep  for  him,  and  subduing  his 
delirium  and  restlessness. 

Attention  must  be  paid  to  the  functions  of  the  gastro- 
intestinal tract,  liver  and  kidneys,  and  it  must  not  be  for- 
gotten that  the  skin  is  a  most  important  organ  of  elimination. 
The  comfort  of  the  patient  must  be  carefully  looked  after — 
much  depends  on  the  withdrawal  of  all  powerful  sensory 
stimuli  during  a  fever — quiet  and  freedom  from  emotional 
disturbance  is  essential,  and  serious  effort  must  be  made  to 
procure  sleep.  The  effect  of  a  sense  of  well-being  on  the 
patient  is  being  more  and  more  realised  in  the  treatment  of 
disease,  and  it  is  a  matter  of  common  knowledge  that  the 
removal  of  an  apparently  trivial  but  troublesome  symptom 
may  influence  favourably  the  course  of  a  grave  illness.  The 
height  of  the  temperature  may  in  itself  call  for  treatment, 
although  it  is  to  be  remembered  that  fever  is  only  a  symptom 
of  a  generalised  diseased  condition,  and  that  interference  by 
certain  methods  with  this  symptom  may  be  attended  by  the 
worst  results.  It  is  a  good  rule  never  to  give  antipyretic 
drugs.  In  doses  suificient  to  reduce  temperature  they  are  apt 
to  induce  collapse,  and  sometimes  death  from  cardiac  failure. 
Most  physicians  have  had  the  experience  of  being  called  in  to 
see  a  case  of  pneumonia  or  enteric  fever  which  has  been 
treated  with  antipyretic  drugs  in  a  comparatively  early  stage 
of  the  disease,  and  have  found  the  patient  cyanosed  and  col- 
lapsed, with  a  feeble  flickering  pulse  and  every  sign  of  im- 
minent death.  The  height  of  the  temperature  in  itself  is  a 
matter  of  small  import.  It  is  the  effect  of  the  high  temperature 
and  the  general  toxaemia  on  the  cardiac  strength  and  cerebral 
mechanism  of  the  patient  that  the  physician  must  observe 
with  care  and  combat  if  necessary.  Fever,  if  too  high  for 
safety,  or  continued  in  high  registers  for  a  prolonged  period, 
should  be  reduced  by  external  applications  of  tepid,  cold  or 


6  Chapter  I. 

iced  water,  either  by  sponging,  packing,  applying  compresses 
or  bathing.     Where  such  applications  fail  to  give  the  patient 
relief  it  is  not  probable  that  any  known  drug  will  reduce  the 
temperature  without  jeopardising  the  safety  of  the  patient.  In 
one  or  two  instances,  apart  from  malaria,  quinine  may  be  of 
service.     The  diet  should  be  fluid  and  bland;  milk,  prepared 
and  modified,   if  necessary,   in  various  ways,    should   be  the 
chief  article  of  food,  alternated  with  clear  soups,  rich  in  ex- 
tractives.      The    extractives    supply    a    stimulus    to    gastric 
secretion  similar  to  the  normal  psychic  stimulation  in  health. 
Soluble  carbohydrates  may  be  added  to  the  milk  in  some  cases, 
and  certain  specially  prepared  proprietary  foods  will  be  found 
to    be    of    use.        Of    these    special    foods    many    are    almost 
entirely  nitrogenous,  and  are  given  with  the  object  of  directly 
repairing  tissue  waste,  e.g.,  somatose    and  plasmon.       Cath- 
cart's  experiments  have  shown  that,  without  a  due  proportion 
of  carbohydrate  admixture,  nitrogenous  food  is  quite  incap- 
able of  preserving  or  replacing  nitrogenous  tissue-wasting,  and 
it  has  always  been  my  principle  in  the  dieting  of  fevers  to 
supply  as  much  soluble  carbohydrate  as  can  be  tolerated  by 
the  patient,  in  the  belief  that  by  this  means  an  easily  com- 
bustible material  is  offered  to  the  body  and  the  proper  utilisa- 
tion of  the  nitrogenous  food  in  the  dietary  assured.       I  can- 
not see  that  benefit  ensues  from  the  exhibition  of  gelatine. 
It  is  an  end-product,   and  save  as  a  vehicle  for  sugar  and  a 
way  of  inducing  a  patient  to  take  milk,  can  be  of  little  ser- 
vice in  nutrition.     Tea  and  coffee  well  diluted  with  milk  form 
a  very  useful  adjunct  to  the  dietary  of  the  fevered.       Many 
people  who  have  a  distaste  for  milk  in  the  natural  state  may 
be  induced  to  take  fairly  large  quantities  when  it  is  sweetened 
and  flavoured  with  coffee,  while  the  action  of  caffeine  is  not  to 
be  despised  in  the  treatment  of  fevers,  especially  those  of  long 
duration.     The  addition  of  eggs,  raw  and  cooked,  to  the  food 
of  those  suffering  from  fever  will  be  discussed  later.     During 
convalescence,  a  mixed  diet  should  be  gradually  resumed,  but 
its  hasty  resumption  is  to  be  avoided,  save  in  moderate  cases 
of    typhus    and    smallpox,    as    much    permanent    damage    to 
digestion  has  often  been  done  by  careless  and  hasty  feeding 
after  many  of  the  acute  fevers.     Water  may  be  given  freely. 


Introductory.  7 

It  encourages  elimination,  and  its  deprivation  is  a  source  of 
irritation  to  a  patient  whose  mouth  is  parclied  and  dry.  It 
should  he  given  frequently  and  in  small  quantities.  Regu- 
larity in  feeding  is  of  great  importance,  but  sleep  should  not 
be  interfered  with  for  the  sake  of  a  feed.  Everything  taken 
should  be  accurately  recorded  by  the  attendant  and  added  up 
at  the  end  of  the  day.  The  mouth  should  be  washed  out 
several  times  a  day  with  a  warm  alkaline  solution  and  the 
teeth  and  gums  should  be  cleaned  before  feeding  with  a  piece 
of  cotton  wool  dipped  in  a  mixture  of  equal  parts  of  glycerine 
of  borax  and  warm  water. 

The  use  of  alcohol  in  the  treatment  of  acute  disease  has 
been  discussed  of  late  years  ad  nauseam.  The  truth  lies,  as 
is  so  often  the  case,  between  the  views  of  the  extremists.  If 
used  with  discretion  and  in  moderation  it  is  often  of  the 
greatest  service;  used  carelessly  and  in  excessive  quantities  it 
is  often  dangerous.  It  is  ridiculous  to  condemn  a  drug  like 
alcohol  because  when  given  indiscriminately  and  to  excess  it 
may  do  harm  to  the  sick  person,  and  it  is  all  the  more 
ridiculous  if  such  condemnation  is  not  the  result  of  unfor- 
tunate experience  in  treating  the  sick,  but  is  due  to  a  fanatical 
hatred  of  alcohol  from  the  social  point  of  view.  Opium, 
chloral,  cocain,  antipyrin  and  phenacetin  have  all  been  used 
by  drug  maniacs  to  satisfy  their  hedonistic  propensities,  yet 
no  sane  person  would  condemn  the  use  of  these  drugs  in 
medical  practice  because,  taken  to  excess  and  apart  from  the 
necessities  of  disease,  they  have  been  the  cause  of  the  final  col- 
lapse in  the  career  of  certain  neurotics.  On  the  other  hand, 
there  is  some  excuse  for  the  anti-alcoholic  enthusiasts.  The 
routine  treatment  of  fevers  by  alcohol  in  doses  which  now 
astonish  us,  was  fairly  common  among  physicians  of  the  last 
generation,  and  like  all  routine  forms  of  drug  treatment,  has 
rightly  fallen  under  suspicion.  There  is  little  doubt,  also, 
that  the  careless  prescribing  of  alcohol  during  convalescence 
has  often  helped  to  revive  or  establish  habits  of  excessive 
alcoholism.  Alcohol,  like  all  other  drugs,  must  be  used,  in 
acute  disease,  only  to  tide  over  certain  emergencies,  and  so 
used,  will  be  found  effective  in  doses  which,  compared  with 
the    daily    allowance    of   5x.    and    5xx.,    which    used    to    be 


8  Chapter  I. 

common  iu  the  treatment  of  typhus,  are  positively  liliputian. 
Apart  from  its  use  as  a  diffusible  stimulant,  alcohol  is  of  the 
greatest  service  as  a  hypnotic  and  sedative  in  many  of  the 
acute  fevers,  and  it  will  rarely  be  found  necessary  to  give 
more  than  511.  to  §iv.  in  the  day,  and  that  only  for  very 
limited  periods.  A  drug  which  can  with  safety  and  in 
moderate  doses  bring  rest  and  sleep  to  a  child  with  whooping- 
cough  or  to  a  patient  with  pneumonia,  or  quiet  the  delirium  of 
typhus,  cannot  be  thrown  aside  to  satisfy  the  prejudices  of 
a  few  who  judge  it  only  by  its  effects  on  society  when  taken 
to  excess  and  apart  from  medical  necessity. 

To  save  re-iteration,  I  think  it  best  to  give'  in  this  introduc- 
tory chapter  certain  details  in  the  management  of  the  patient 
which  are  common  to  all  the  infectious  fevers,  and  to  mention 
under  the  heading  of  "home  prophylaxis"  at  the  end  of  the 
description  of  each  disease  those  particular  points  which  are 
specially  necessary  for  the  disease  under  consideration. 

If  a  patient  is  nursed  at  home  strict  isolation  from  all  ex- 
cept his  immediate  attendants  must  be  maintained.  The 
sick-room  sliould  be  as  large  as  possible,  stripped  of  all  hang- 
ings and  pictures,  and  kept  well  ventilated,  but  I  do  not  think 
that  the  stripping  of  the  carpet  is  necessary  or  even  wise,  if  it 
be  brushed  damp  each  day,  because  it  acts  to  a  certain  extent 
as  a  prevention  against  the  entrance  of  germs  into  the  spaces 
between  the  planks  of  the  floor,  and  can  be  easily  disinfected 
at  the  end  of  the  illness.  A  polished  parquet  floor  is,  of 
course,  the  ideal  for  a  sickroom,  but  this  is  not  often  obtain- 
able in  Great  Britain.  The  hanging  of  carbolised  sheets  over 
the  door  is  of  no  service  in  isolation,  and  the  smell  of  carbolic 
acid  is  ver}-  distasteful  to  many  people.  Similarly,  spray- 
ing or  vaporising  a  room  with  some  carbolic  preparation  is 
equally  useless  and  impleasant.  "Sanitas  Fluid"  or  some 
such  aromatic  disinfectant  in  the  form  of  a  spray  is  useful 
as  a  deodorant.  All  vessels  which  have  been  in  contact  with 
the  patient  or,  indeed,  have  been  in  the  patient's  room,  should 
be  cleansed  with  boiling  water  immediately  after  use.  The 
water  must  not  only  be  hot  but  actually  boiling.  Sheets  and 
body  clothing  should  all  be  steeped  in  a  disinfectant  solution 
and    boiled    before   washing,    and    sponges    should    be    boiled 


Introductory.  9 

frequently.  Brushes  may  be  elfectively  cleaned  by  thorough 
washing  in  a  strong  hot  solution  of  carbonate  of  soda.  It  is 
well  for  the  patient's  attendant  to  have  the  arms  bare  to  the 
elbow;  no  long  sleeves  or  cuffs  should  be  worn  by  a  fever- 
nurse  while  on  duty.  She  should  wear,  while  in  the  sick- 
room, an  overall  which  should  be  changed  every  two  days  and 
steeped  in  1-20  carbolic  solution  and  boiled  before  being  sent 
to  be  washed.  Where  possible,  the  attendant  should  never 
eat  in  the  sick  room,  and  should  always  wash  the  hands  and 
brush  the  nails  thoroughly  before  a  meal.  She  should  eat 
every  four  hours ;  the  food  should  be  light  and  easily  digested ; 
the  meal  should  be  eaten  leisurely;  and  no  one  ought  to  be  in 
charge  of  a  fever  patient  who  is  ansemic,  who  suffers  from 
dyspepsia,  or  whose  teeth  are  not  well  kept  and  free  from 
caries.  All  attendants  on  fever-cases  should  have  two  hours 
daily  in  T^hicli  to  take  the  air,  and  the  time  on  duty  should 
not  be  longer  than  twelve  hours,  inclusive  of  the  time  spent  at 
meals,  30  minutes  at  least  being  allowed  for  each  meal. 
Of  course,  the  exigencies  of  particular  cases  must 
modify  this.  One  has  no  sympathy  with  either  the  physician 
or  the  nurse  who  are  so  bound  down  by  rule  as  to  insist  on 
regular  routine  at  times  of  danger  to  the  patient,  and  it  is  to 
be  remembered  that,  in  the  nursing  of  infectious  cases  in 
private  houses,  the  care  of  the  room  and  of  the  fire  and  the 
preparation  of  simple  food  should  be  cheerfully  undertaken 
by  the  nurse  if  she  is  to  be  of  real  service  to  the  physician  and 
the  patient.  The  position  of  the  nurse  in  a  private  house  is 
often  difficult  and  sometimes  unpleasant,  but  the  physician 
has  daily  to  experience  similar  discomforts  at  the  hands  of 
ignorant  and  arrogant  people,  and  if  a  woman  is  not  possessed 
of  sufficient  tact  and  resource  to  tide  over  such  difficulties 
satisfactorily,  she  should  adopt  any  other  profession  than  that 
of  nursing.  In  nursing,  as  in  every  other  calling,  people 
who  are  continually  insisting  on  their  "rights"  have  a  singu- 
larly unpleasant  time,  while  those  who  quietly  and  without 
fuss  establish  their  position  in  each  new  situation  in  which 
they  find  themselves,  are  surprised  how  pleasant  work  may  be. 
A  change  of  environment  necessitates  a  modification  of  con- 
duct, and  the  fittest  survive. 


FEVEES    OF 
Kl^OWN     BACTERTOLOGY. 


Chapter  II. 

ENTERIC    FEVEE. 

Synonyms.  —  Typhoid  fever  :    Gastric  fever  :    Pytliogenic 
fever. 
French  :      Fievre  typlioide. 
German:    Typhus  Abdominalis ;  Abdominaltyphus. 

Definition. — An  acute  exanthematous  fever,  characterised 
usually  by  a  slovt^  and  insidious  onset,  having  a  duration  of 
some  three  to  five  weeks,  and  associated  with  a  general  blood- 
infection  and  an  invasion  of  the  lymphoid  tissue  of  the  ileum 
causing  infiltration  and  ulceration  of  Peyer's  patches  and  the 
solitary  follicles,  by  a  specific  organism,  the  B.  typhosus,  dis- 
covered by  Eberth  in  1880. 

Incubation  Period. — This  is  extremely  variable,  from  2 
to  21  days,  the  usual  period  being  from  10  to  15  days. 

Rash. — The  rash  of  enteric  fever  is  very  typical.  About 
the  6th  to  the  10th  day  of  the  disease,  small  "rose-spots"  ap- 
pear on  the  skin,  the  abdomen  being  the  most  usual  situation. 
They  are  slightly  raised  above  the  surface  of  the  skin,  and  when 
firmly  pressed  upon  disappear  for  a  moment.  The  duration 
of  each  spot  is  three  or  four  days,  but  they  tend  to  appear  in 
successive  "crops,"  so  that  the  eruption  may  be  A'isible  for 
weeks.  In  most  cases  the  spots  have  all  faded  some  10  days 
after  the  first  has  appeared.  As  a  rule  the  eruption  is  scanty, 
limited  to  a  few  spots  on  the  abdomen,  but  in  some  cases  the 
whole  abdomen  and  the  lower  part  of  the  chest  may  be  thickly 
covered  with  typical  rose-spots,  while  in  other  cases  the  skin 
of  the  body  generally  may  present  a  very  abundant  rash.  The 


Enteric  Fever.  11 

rash  is  present  in  a  large  proportion  of  all  cases  of  enteric 
fever,  but  cases  do  occur  in  which  no  rash  is  visible,  and  an 
eruption  of  rose-spots,  quite  indistinguishable  from  a  true 
enteric  fever  rash,  is  sometimes  met  with  in  cases  of 
abdominal  tuberculosis  and  acute  or  subacute  gastro-intestinal 
catarrh,  so  that  a  typical  eruption  of  rose-spots,  although  it 
may  strongly  suggest  enteric  fever,  is  by  no  means  patho- 
gnomonic. 

A  tdclie  hletidtre  having  the  appearance  of  faint  violet 
finger-tip  marks  has  been  frequently  observed  as  a  prodromal 
rash,  or  appearing  in  conjunction  with  the  ordinary  rash,  but 
as  it  occurs  in  many  conditions  other  than  enteric  fever  it  is 
of  no  diagnostic  value. 

Clinical  types, — Period  of  Invasion :  It  is,  in  most 
instances,  a  matter  of  extreme  difficulty  to  fix  accur- 
ately the  beginning  of  the  period  of  invasion  in 
enteric  fever.  The  onset  of  the  disease  is  commonly 
so  insidious  and  the  symptoms  so  slight  at  the  com- 
mencement, that  it  takes  the  patient  several  days  to  discover 
that  his  health  is  much  below  normal.  He  usually  becomes 
gradually  aware  that  his  appetite  is  poor  and  his  tongue  furred ; 
he  has  a  "bad  taste  in  the  mouth,"  while  he  suffers  from  a 
feeling  of  slight  general  malaise  and  listlessness ;  he  may  have 
some  headache  and  find  that  his  powers  for  work  are  below 
normal.  In  other  words,  he  feels  unaccountably  "run  down," 
and  at  this  stage  of  his  illness,  if  he  be  a  person  of  sedentary 
occupation,  he  frequently  takes  more  exercise  than  usual  in 
the  hope  of  bracing  himself  up.  In  spite  of  this,  however, 
he  finds  that  the  feeling  of  lassitude  grows,  and  he  is  con- 
scious of  a  real  increasing  enfeeblement,  which  at  last  makes 
him  take  to  bed,  while  headache,  which  may  have  been  only 
slight  and  transitory  at  first,  very  frequently  becomes  an 
urgent  symptom.  At  the  same  time  he  may  suffer  from  deaf- 
ness, and  his  friends  notice  that  he  is  a  curious  compound  of 
listlessness  and  irritability.  Sore  throat,  with  congestion  of 
the  fauces  and  tonsils,  is  a  frequent  symptom.  The  period  of 
invasion  lasts  usually  for  about  a  week,  sometimes  more  and 
rarely  less,  and  it  is  in  this  period  that  a  patient  may  do 
himself  unconscious  harm  by  endeavouring  to  'Svork  off"  what 


12  Chapter  II. 

appears  to  him  to  be  a  slight  temporary  ailment.  In  a  small 
proportion  of  cases  the  period  of  invasion  is  short  and  the 
symptoms  urgent.  The  patient  may  be  suddenly  seized  to  all 
appearance  with  an  acute  pneumonia,  and  only  the  subsequent 
course  of  the  illness  will  shew  that  the  pneumonia  has  been 
due  to  an  invasion  of  the  B.  typhosus.  In  certain  of  the 
cases  with  sudden  onset  the  disease  may  simulate  an  attack 
of  scarlet  fever,  with  high  temperature  from  the  onset,  in- 
flamed fauces  and  tonsils  and  a  bright  scarlatiniform  rash, 
and  it  is  only  when  the  rash  fades  without  abatement  of  the 
fever  and  the  characteristic  "rose-spots,"  which  in  such  cases 
are  usually  yerj  profuse,  appear,  that  enteric  fever  is  even 
suspected.  In  other  cases  a  rapid  and  severe  onset  is  not 
attended  by  any  such  manifestations  as  to  make  the  attack 
likely  to  be  confused  with  any  other  of  the  acute  eruptive 
fevers,  and  it  is  in  such  cases  that  a  hasty  diagnosis  of 
"  influenza"  is  often  made. 

In  those  cases  with  a  scarlatiniform  prodromal  rash  the 
pulse-rate  is  a  help  in  the  differential  diagnosis,  since  even  in 
such  cases  the  comparatively  slow  pulse,  so  generally  met 
with  in  the  early  stages  of  enteric  fever,  is  the  rule.  In  a 
few  cases  the  period  of  invasion  is  characterised,  perhaps  after 
a  day  or  two  of  indefinite  malaise,  by  violent  symptoms  of  a 
cerebral  kind.  The  patient  may  be  wildly  delirious,  or  com- 
pletely unconscious ;  he  may  complain  of  severe  headache,  may 
suffer  from  vomiting  of  a  cerebral  type,  have  an  irregular 
pulse,  and  exhibit  a  typical  '^tache  cerebrale,"  and  such 
cases  are  often  reasonably  mistaken  for  meningitis. 

The  bowels  during  the  period  of  invasion  are  frequently 
constipated,  more  rarely  loose.  It  is  very  common  during 
this  stage  of  the  disease  to  find  a  little  diffuse  bronchial 
catarrh,  which  may  lead  the  practitioner  astray,  especially  as 
fever  may  be  moderate,  and  even,  save  in  the  evening,  absent. 

As  a  rule,  the  physician  is  called  to  see  the  patient  just 
as  the  period  of  invasion  is  over  and  the  fastigium  is  reached. 
In  the  typical  or  classical  case  the  patient  lies  on  the  back, 
disinclined  to  move,  his  whole  attitude  being  one  of  profound 
exhaustion.  The  face  generally  is  pale,  with  some  flushing 
in  the  malar  regions.       The  eyes  are  clear  and  the  pupil  is 


Enteric  Fcuei'.  V-*) 

most  usually  dilated.  The  tongue  is  coated  at  the  back  and 
centre  with  a  white  creamy  fur  and  the  patient  is  conscious 
of  a  disagreeable  taste  in  the  mouth  and  has  lost  all  appetite. 
The  pulse  is  moderate  in  rate,  between  80  and  90  liei  minute, 
although  the  temperature  may  be  ranging  between  101°  and 
103°  F.  Respirations  are  quiet  in  the  absence  of  any  pul- 
monary implications,  or  where  there  is  only  the  slight  catarrh 
of  the  larger  bronchi  that  is  so  commonly  met  with.  Head- 
ache may  be  a  troublesome  symptom  and  may  interfere  with 
sleep.  Deafness  is  more  often  present  than  not,  and  although 
usually  slight,  may  be  almost  complete.  So  frequently  is 
deafness  a  symptom  in  the  early  stages  of  the  disease  that 
an  unexplained  rise  of  temperature  continuing  over  some  days 
and  associated  with  deafness,  should  always,  in  the 
absence  of  any  gross  lesion  of  the  middle  ear,  suggest 
to  the  mind  of  the  physician  that  the  illness  is  enteric 
fever.  The      spleen      is      usually      appreciably      enlarged 

after  the  eighth  day.  The  abdomen  is  often  slightly  dis- 
tended, more  particularly  in  the  right  iliac  region,  and 
manipulation  in  this  region  may  give  rise  to  a  feeling  of  dis- 
comfort on  the  part  of  the  patient,  and  the  physician  may  be 
aware  of  some  gurgling  under  his  hand.  Examination  of  the 
abdomen  should  always  be  made  with  the  greatest  care,  as 
rough  handling  may  precipitate  the  occurrence  of  haemorrhage 
or  a  general  peritonitis.  The  fastigium  is  said  by  older 
writers  to  last  for  a  week,  but  it  is  seldom  that  its  duration  is 
so  short,  save  in  the  mildest  cases.  In  cases  even  of  moderate 
severity  it  is  usually  prolonged  to  10  days  or  a  fortnight,  and 
it  is  characterised  by  an  increase  in  the  symptoms  described 
above.  The  patient's  feebleness  is  striking;  even  slight  move- 
ment is  an  effort,  and  he  needs  constant  attention  from  the 
nurse.  The  fur  on  the  tongue  becomes  brown  and  sordes  is 
apt  to  collect  on  the  teeth.  Emaciation  is  marked.  As  the 
third  week  of  the  disease  is  entered  upon,  there  is  a  tendency 
for  congestion  to  appear  at  the  bases  of  the  lungs,  the  pulse 
grows  rapid  and  very  soft,  while  delirium,  sometimes  low  and 
muttering,  sometimes  loud  and  violent,  may  be  present.  The 
intestines  may  be  distended  with  flatus,  and  colicky  pains  are 
sometimes  very  troublesome.     A  little  vague  pain  apart  from 


14  Chapter  II. 

colic  is  sometimes  felt  in  the  right  iliac  fossa,  but  this  is 
rarely  more  than  a  slight  uneasiness.  Throughout  the  fastigium 
the  temperature  remains  fairly  high,  between  101°  and  103° 
F,  as  a  rule,  with  sometimes  a  rise  to  104°  F.,  and  the  daily 
variation  is  rarely  more  than  2°  P.,  so  that  the  fever  is  at 
this  stage  of  the  "continued"  type.  Diarrhoea  may  be 
troublesome,  four  or  five  motions  in  the  day  being  not  un- 
common, and  sometimes  the  patient  is  troubled  with  very 
frequent  small  evacuations.  But  constipation  is  quite  as 
common,  necessitating  the  moving  of  the  bowels  by  artificial 
means,  either  by  drugs  or  enemata. 

In  a  simple  uncomplicated  case,  even  of  fair  severity,  one 
may  reasonably  expect  an  abatement  of  the  disease  at  some 
time  in  the  third  week,  or  after  the  fastigium  has  been  main- 
tained for  some  8  or  10  days.  The  morning  remissions  of 
temperature  become  greater,  although  in  the  early  stages  of 
the  i^eriod  of  declension  the  evening  temperature  may  be 
maintained  at  its  former  high  level.  Gradually  the  morning 
remissions  fall  to  a  lower  level,  the  evening  exacerbations  fail 
to  reach  the  height  of  the  previous  day,  and  the  fever  declines 
by  a  gradual  lysis,  which  may  proceed  for  a  week  or  a  fort- 
night before  the  evening  temperature  remains  normal.  Rarely 
the  fever  terminates  by  crisis,  slightly  less  rarely  by  a  rapid 
lysis  occupying  only  two  or  three  days.  Occasionall}^  at  the 
beginning  or  during  the  course  of  the  lysis,  the  temperature 
may  shew  very  large  daily  excursions.  It  may  rise  suddenly, 
sometimes  associated  with  rigor,  to  very  high  registers,  even 
105°  or  106°  F.,  and  may  fall,  with  signs  of  collapse  on  the 
part  of  the  patient,  to  normal  or  subnormal  levels  in  a  few 
hours.  This  "swinging"  temperature  may  continue,  in 
varying  degree,  for  some  days,  and,  although  it  is  not  in 
itself  a  particularly  ominous  sign,  shew^ing  as  it  does  that 
the  patient  is  capable  of  powerful  reaction,  it  may  cause  alarm 
to  the  patient's  friends  and  to  those  among  his  attendants  who 
are  not  familiar  with  the  conditions.  It  usually  occurs  in  a 
severe  attack  of  enteric  fever,  and  is,  I  think,  indicative  of 
the  sudden  separation  of  extensive  sloughs  in  the  intestine. 
With  the  declension  of  the  fever,  the  patient  becomes  less 
dazed  and  delirious,  the  tongue  becomes  cleaner  and  there  is 


Enteric  Fever.  15 

an  increasing  tendency  to  sleep.  The  pulse  grows  less  rapid, 
and  begins  to  recover  its  tone.  If  bronchial  catarrh  or  pul- 
monary congestion  has  been  present  it  tends  to  disappear, 
while  the  patient  may  regain  his  appetite  to  a  considerable 
extent,  even  before  the  temperature  has  reached  normal.  Dis- 
tension of  the  abdomen  passes  away,  and,  when  diarrhoea  has 
been  a  feature  in  the  case,  the  stools  become  less  frequent. 
When  constipation  has  been  present,  however,  there  is  usually 
no  corresponding  relaxation  of  the  bowels,  which  may  require 
to  be  moved  artificially  well  into  the  period  of  convalescence. 
The  stools  in  a  case  of  enteric  fever  which  is  not  constipated 
are  often  very  typical,  being  loose  and  yellow  in  colour  during 
the  first  fortnight,  so  that  they  have  been  likened  to  pea  soup. 
Their  odour  is  usually  rather  offensive.  During  the  third 
week  of  the  disease  their  appearance  alters  and  they  become 
greenish  in  colour  and  may  contain  sloughs. 

After  the  temperature  has  remained  normal  for  about  a 
week,  one  may  say  in  most  cases  that  convalescence  is  es- 
tablished and  that  the  further  progress  of  the  case  will  be 
uneventful,  although  relapses  have  been  known  to  occur  long 
after  that  period. 

Such  is  the  course  of  the  moderatel}^  severe  and  uncompli- 
cated case  of  enteric  fever,  but  the  type  of  the  disease  varies 
very  much  in  different  epidemics,  so  that  in  some  years  this 
moderate  type  forms  the  vast  majority  of  the  cases  met  with, 
while  in  others  a  much  more  severe  type  occurs  with  great 
frequency. 

A  Tnore  severe  type  is  that  in  which  the  fastigium  is 
ushered  in  by  high  fever  with  marked  nervous  symptoms, 
much  diarrhoea,  and  an  early  tendency  to  pulmonary  con- 
gestion. In  such  cases  the  abdomen  is  frequently  enormously 
distended  with  flatus  and  the  patient  may  suffer  much  from 
colic.  The  early  delirium  and  restlessness  combined  with 
great  cardiac  enfeeblement  make  the  patient's  recovery  a 
matter  of  doubt  from  a  very  early  stage,  apart  from  the  occur- 
rence of  any  complication.  In  many  of  these  cases  death 
occurs  from  sheer  toxaemia  late  in  the  second  or  early  in  the 
third  week,  with  very  high  temperature  and  rapidly  failing 
heart.        In      such     cases     the     face     and     even     the      skin 


16  Chapter  II. 

generally  are  dusky  and  livid,  and  the  extremities 
are  frequently  very  cold.  Where  recovery  does  take  place,  it 
is  only  after  a  prolonged  fever,  slow  declension,  and  very 
tedious  convalescence. 

On  the  other  hand  certain  cases  of  enteric  fever  present  a 
type  of  the  disease  so  mild  that  it  is  difficult  of  recognition. 
It  is  sometimes  so  slight  that  the  patient  may  be  conscious 
only  of  a  little  general  malaise  and  may  never  take  to  bed  or 
consult     a     physician.  Such     cases     are     described     as 

" ambulato7'y ,"  and  are  extremely  dangerous  to  the  community 
from  their  capacity  for  widely  spreading  infection.  Attacks 
of  "ambulatory"  enteric  fever  are  not  without  their  danger 
to  the  patient,  since,  in  spite  of  their  mildness,  they  may  be 
attended  by  one  or  other  of  the  more  dangerous  complications 
of  the  disease,  and  a  haemorrhage  from  the  bowel,  a  perfora- 
tion of  the  intestine,  or  a  severe  venous  thrombosis  may  make 
it  plain  that  the  patient  is  the  subject  of  a  grave  disorder, 
although  his  symptoms  up  to  the  time  of  such  an  occurrence 
may  have  been  of  the  most  trifling  description.  In  other 
cases  the  disease,  although  very  mild  in  type,  is  sufficiently 
marked  to  make  the  patient  take  to  bed.  He  may  have  no 
nervous  symptoms,  no  pulmonary  congestion  or  bronchial 
catarrh ;  his  sleep  may  not  be  interfered  with ;  his  bowels  may 
be  normal  in  their  action,  and  save  for  a  slight  daily  fever  and 
sense  of  weakness,  no  symptom  may  present  itself  that  is 
apparently  worthy  of  serious  attention.  Even  in  such  mild 
cases,  however,  the  spleen  may  be  perceptibly  enlarged  during 
the  second  week,  and  an  eruption  of  rose-spots  may  be  present. 
It  is  of  the  greatest  importance  to  the  patient  who  suffers  from 
a  mild  attack  that  his  physician  should  be  fully  alive  to  the 
gravity  of  the  condition,  because,  as  in  the  "ambulatory" 
type  of  the  disease,  complications  may  arise  that  may  threaten 
life,  and  any  laxity  in  treatment  may  readily  encourage  their 
occurrence. 

Complications. —  The  more  common  complications  to  be  met 
with  in  enteric  fever  are  :  — 

1.  Perforation  of  one  of  the  ulcers  in  the  ileum. 

2.  Eupture  of  a  suppurating  mesenteric  gland. 


Enteric    Fever.  17 

3.  General  peritonitis  without  an  apparent  local 
focus. 

4.  Haemorrhage  from  the  bowel. 

5.  Yenous  thrombosis. 

6.  Arterial  thrombosis  and  the  formation  of  abs- 
cesses in  the  subcutaneous  or  inter-muscular  connective 
tissue. 

7.  Lymphangitis. 

1.  Perforation  of  the  Intestine. — This  is,  perhajis,  the 
g-ravest  of  all  the  complications.  While  its  occurrence  is 
easily  recognised  when  the  symptoms  are  typical,  it  is  often 
difficult  of  recognition  on  account  of  the  masking  of  the 
symptoms  by  the  general  condition  of  the  patient.  The 
symptoms  usually  described  as  tyj^cal  of  the  occurrence  of 
perforation  are  severe  pain  in  the  right  iliac  region,  accom- 
panied by  a  feeling  of  great  distress  on  the  part  of  the  patient 
and  the  general  facies  of  collapse.  Yomiting  may  be  present. 
The  temperature  falls  and  the  pulse-rate  rises.  The  rise  in 
the  pulse-rate  may  be  followed  in  an  hour  by  a  fall  to  its 
primary  level,  but  thereafter  it  gradually  rises  again.  The 
abdomen  is  distended;  there  is  an  encroachment  on  the 
hepatic  dullness  and  possibly  on  the  splenic  dullness.  Respira- 
tion is  thoracic  in  type  and  increased  in  rate.  The  patient's 
expression  is  anxious  and  "pinched,"  and  his  strength  is 
rapidly  reduced,  so  that  speech  is  faint  and  difficult.  The 
abdomen  is  rigid,  either  generally  or  only  on  the  right  side. 
Sweating  is  not  usually  a  marked  symptom  in  the  early  stages 
of  perforation,  though  it  may  occur  in  association  with  a 
wide-spread  general  peritonitis.  It  is  true  that  if  all  these 
signs  and  symptoms  are  present,  no  one  can  help  making  a 
diagnosis  of  perforation,  but,  unfortunately,  it  is  not  the  rule 
that  all  such  signs  and  symptoms  appear  early  after  the  occur- 
rence of  perforation,  and,  if  they  are  present  early,  it  augurs 
badly  for  the  success  of  the  one  form  of  treatment  which  offers 
any  hope  to  the  patient,  operative  interference.  A  certain 
amount  of  pain  is  usually  present,  but  it  may  not  be  severe 
and  stabbing  in  character,  and  may  not  be  associated  with 
the  typical  facies  of  collapse.  The  temperature  may  fall,  but 
for  about  an  hour  after  perforation  has  occurred  it  may  remain 


18  Chapter  11. 

stationary  or  even  rise.  Alter  that  time,  however,  it  falls,  to 
some  extent  at  least.  The  type  of  respiration  may  or  may 
not  be  altered.  The  patient's  expression,  however,  is  always 
anxious  and  slightly  "pinched,"  suggestive  of  some  occurrence 
out  of  the  ordinary,  and  as  a  general  rule  the  pulse-rate  is  dis- 
tinctly raised.  The  occurrence  of  abdominal  pain,  accom- 
panied by  rise  in  pulse-rate  and  some  rigidity,  either  general 
or  limited,  of  the  abdominal  wall,  and  a  new  anxious  look  oii 
the  patient's  face,  are  the  signs  which  should  make  the 
physician  at  least  suspect  the  occurrence  of  perforation,  and 
take  immediate  steps  accordingly.  To  wait  until  the 
diagnosis  is  completed  by  the  occurrence  of  abdominal  disten- 
sion and  encroachment  on  or  disappearance  of  the  liver-dullness 
is,  in  view  of  modern  surgical  technique,  criminal.  In  many 
cases  the  abdomen  may  be  rather  sunken  for  a  little  time  after 
the  occurrence  of  perforation,  and  by  the  time  that  it  has 
become  distended  all  hope  of  successful  interference  may  be 
gone. 

Tn  certain  cases  ihe  gut  may  be  so  distended  as  to  dis- 
place the  heart  and  cause  disappearance  or  diminution  of  the 
prsecordial  area  of  dullness,  and  similarly  the  hepatic  area  of 
dullness  may  be  greatly  lessened,  without  the  occurrence  of 
perforation.  The  sudden  onset  of  a  pleurisy  or  a  heemorrhagic 
infarction  in  the  lower  part  of  the  right  lung  may  give  rise,  by 
referred  pain,  to  a  simulation  of  an  attack  of  perforation.  I 
have  known  one  patient  operated  on  after  such  an  occurrence, 
and  it  was  only  on  post-mortem  examination  that  the  existence 
of  a  large  hsemorrhagic  infarction  in  the  lower  lobe  of  the 
right  lung  was  discovered.  Sometimes  before  the  occur- 
rence of  a  perforation  of  the  intestine  the  patient  may 
complain  for  some  hours  of  considerable  pain  in  the  right 
iliac  fossa  without  other  symptoms.  This  has  been  called 
"pre-perforative"  pain.  Occasionally,  one  or  two  loose 
motions,  streaked  with  blood,  in  a  case  not  previously 
afflicted  with  diarrhoea, may  immediately  precede  a  perforation. 
2.  Rupture  of  a  {Suppurating  gland  presents  symptoms 
practically  identical  with  those  of  perforation  of  the  intestine, 
but  on  the  occurrence  of  rupture  the  temperature  rises  at 
once. 


Enteric   Fever.  19 

3.  General  peritoiiitis  loithout  perforation  of  f/ie  intestine 
or  rupture  of  a  gland. — This  condition  is  coiupuratively 
rure,  but  Macrae  of  Glasgow  lias  met  with  it  in  ten  out  of 
sixty-six  cases  of  general  peritonitis  in  enteric  fever  on  which 
he  has  operated.  The  symptoms  are  those  ordinarily  met  with 
in  general  peritonitis  from  any  cause,  and  it  is  only  on 
operation,  sometimes  followed  by  more  detailed  observation 
post-mortem,  that  the  true  nature  of  the  condition  has  been 
discovered.  In  such  cases  the  most  careful  search  fails  to 
reveal  any  local  focus,  and  one  can  only  come  to  the  conclusion 
that  the  peritonitis  is  due  to  the  general  blood  infection  either 
directly  or  through  the  medium  of  several  tiny  venous  or 
arterial  thromboses  such  as  are  met  with  elsewhere. 

4.  Ho27norrhage  from,  the  bowel  is  a  complication 
which  is  met  with  frequently,  and  its  severity  is  very  variable. 
The  amount  of  blood  lost  may  amount  only  to  a  few  drachms, 
or  it  may  resemble  a  post-partum  haemorrhage  and  be  so  pro- 
fuse as  to  soak  the  m.attress.  Like  all  complications  of 
enteric  fever  it  usually  occurs  in  the  third  or  fourth  week  of 
the  disease,  or,  to  put  it  in  another  way,  at  some  time  after 
the  process  of  ulceration  has  begun.  But  hsemorrhage  is  not 
always  associated  with  deep  ulceration  of  the  intestine.  The 
most  copious  hsemorrhage  which  I  ever  saw  in  enteric  fever 
occurred  in  the  old  i'ever  Hospital  in  Paisley,  and  was  so 
profuse  that  within  an  hour  the  mattress  was  soaked  through 
and  blood  dripped  on  the  floor.  Post-mortem  examination 
revealed  no  deep  ulceration  of  Peyer's  pafches,  but  only  an 
enormous  number  of  the  fine  haemorrhagic  points  situated  in 
the  last  two  feet  of  ileum  and  associated  with  an  extraordinary 
congestion  of  the  whole  mucous  membrane.  The  patient  was 
a  woman  who  had  had  ordinary  menstrual  periods  and  whose 
family  showed  no  trace  of  the  hsemorrhagic  diathesis.  Apart 
from  these  rare  cases  of  intestinal  flooding,  the  amount  of 
blood  lost  during  the  attack  has  little  value  as  regards  prog- 
nosis. In  some  of  the  most  rapidly  fatal  cases  which  I  have 
seen,  the  amount  of  blood  lost  has  been  trifling,  although  the 
haemorrhage  has  been  repeated  many  times.  I  speak  now  only 
of  those  cases  where  the  amount  of  blood  lost  has  been  small 
and  where  no  large   amount  of  clot  has  been  found   in   the 


C      ^ 


20  Chapter  II. 

bowel  post-moitem.  It  is  uecessaiy  to  be  thus  explicit,  as  in 
many  cases  where  the  loss  of  blood  has  been  apparently 
trilling,  post-mortem  examination  has  revealed  the  existence 
of  a  large  concealed  haemorrhage.  It  is  of  the  greatest  im- 
portance for  the  practitioner  to  realise  the  significance  of 
haemorrhage  as  regards  prognosis,  and  one  should  always  give 
a  guarded  prognosis  when  haemorrhage  has  occurred,  however 
slight  the  amount  may  be,  since  the  passage  of  a  merely  blood 
streaked  stool  may  be  followed  by  the  occurrence  of  a  fairly 
copious  flow  of  bright  blood,  the  passage  of  a  stool  consisting 
almost  entirely  of  clots,  or  a  large  stool  of  faecal  material 
intimately  mixed  with  dark  altered  blood.  The  prognosis 
must  always  be  given  after  consideration  not  only  of  the 
amount  of  the  haemorrhage  but  of  the  other  signs  and 
symptoms  which  the  patient  may  present.  My  own  experience 
has  always  led  me  to  give  a  very  grave  prognosis  when 
liaemorrhage  occurs,  even  though  slight,  with  a  rising  tem- 
perature and  pulse-rate,  which  is  not  disturbed  by  the  occur- 
rence of  the  bleeding.  On  the  other  hand,  a  slight 
haemorrhage,  occurring  towards  the  period  of  declension,  not 
accompanied  by  any  very  grave  signs  of  general  disturbance, 
may  augur  nothing  of  danger  if  accompanied  by  a 
sudden  and  well  marked  fall  in  temperature,  and  I  have 
known  cases  which  have  terminated  favourably  by  a  crisis 
which  followed  on  the  occurrence  of  a  large  haemorrhage. 
Haemorrhage  in  a  patient  who  shows  marked  signs  of  toxaemia 
is  always  a  grave  symptom,  because  in  such  profoundly 
poisoned  cases  it  is  often  repeated,  and  is  dangerous,  like 
frequent  diarrhoea,  if  only  on  account  of  the  extra  movement 
of  the  patient  which  it  involves,  while  it  indicates  a  condition 
of  great  gravity  in  the  same  way  as  does  the  haemorrhagic  type 
of  other  acute  fevers.  It  is  common  to  publish  charts  which 
show  a  considerable  fall  in  temperature  at  the  occurrence  of  a 
haemorrhage,  but  while  this  does  frequently  occur,  sometimes 
with  all  the  symptoms  of  profound  collapse,  lividity  and 
coldness  of  the  skin,  accompanied  by  profuse  cold 
sweating,  a  haemorrhage  may  occur  without  the  slightest  dis- 
turbance of  the  temperature  curve.  Most  commonly  no 
general  symptoms  give  warning  of  the  attack,   but  in  some 


Enteric   Fever.  21 

cases  the  patient  may  suddenly  collapse,  complain  of  a  vague 
abdominal  discomfort,  and  have  a  general  sense  of  uneasiness ; 
he  may  grow  livid  and  cold,  the  temperature  may  fall,  the 
pulse-rate  rise  and  beads  of  cold  perspiration  stand  out  on  his 
face,  and  it  may  not  l)e  till  upwards  of  un  hour  afterwards 
that  occurrence  of  an  intestinal  haemorrhage  may  explain  the 
general  disturbance.  Such  cases  may  for  a  moment  suggest 
perforation,  but  the  absence  of  pain  and  of  the  pinclied 
"abdominal"  facies  will  guide  in  the  formation  of  a  diagnosis, 
and  in  any  case  the  haemorrhage  will  have  declared  itself 
before  any  surgical  interference  can  be  made.  Profuse  cold 
sweating  is  always  a  grave  symptom  in  association  Avith 
haemorrhage. 

5.  Venous  tJirombosis  is  often  a  troublesome  com- 
plication, and,  as  in  puerperal  septicai^mia,  one  or  other 
femoral  vein  is  its  commonest  situation.  It  occurs  also  in 
the  saphenous  and  popliteal  veins  and  has  been  observed,  very 
rarely,  in  the  axillary  and  sub-clavian  veins.  Such  throm- 
bosis is  usually  one-sided.  It  occurs  late  in  the  disease,  and 
may,  indeed,  appear  only  during  the  period  of  convalescence. 

6.  Arterial  thrombosis  and  ahscess- formation  in  the  sub- 
cutaneous or  intermuscular  connective  tissue. — Thrombosis 
of  any  of  the  larger  arteries  is  a  comparatively  rare  condition, 
but  it  has  been  observed  as  giving  rise  to  gangrene  of  the 
toes,  the  whole  foot,  and  even  of  the  leg  to  above  the  knee, 
the  arteries  usually  involved  being  the  femoral,  popliteal  or 
posterior  tibial.  The  middle  cerebral  artery  has  also  been 
described  as  being  the  seat  of  thrombosis,  giving  rise  to 
apoplectiform  and  convulsive  attacks.  Such  thrombosis 
occurs  usually  in  the  third,  fourth  or  fifth  weeks  of  the 
disease. 

But  it  seems  likely  that  thrombosis  of  small  arterial 
twigs  is  fairly  common.  It  is  difficult  to  explain  otherwise 
the  occurrence  of  those  subcutaneous  and  intermuscular  ab- 
scesses that  are  so  frequently  met  with  late  in  the  disease. 
The  thigh,  leg,  lumbar  region  and  buttocks  are  the  com- 
monest sites  for  such  abscesses,  but  they  may  occur  au3^wliere. 


22  ChapUr  11. 

7.  LyTnphangitis. — As  in  puerperal  infectioiivS,  a  lym- 
phangitis of  the  thigh  is  a  fairly  common  complication  of 
enteric  fever,  and  it  is  very  likely  that  many  cases  of  swelling 
and  pain  in  the  thigh  have  been  labelled  as  venous  throm- 
liosis  -which  were  really  lymphangitis.  Many  believe  that 
lymphangitis  is  much  more  common  in  enteric  fever  than 
venous  thrombosis,  and  there  is  much  evidence  in  support  of 
their  view.  The  diffuse  tenderness  and  the  uniformly  pale 
colour  of  the  swelling,  are  points  in  favour  of  the  diagnosis 
of  lymphangitis. 

Other  complications  occur  in  enteric  fever,  all  about 
the  third  or  fourth  week  in  the  disease,  that  are  suffi- 
ciently uncommon  to  merit  only  a  word  in  passing.  Cystitis 
and  pyelitis  may  occur  from  infection  of  the  urinary  tract  by 
the  B.  typhosus.  The  prognosis  in  both  these  conditions  is 
generally  favourable,  since  we  are  dealing  with  an  in- 
fection upon  which  Nature  has  put  a  more  or  less  definite 
limit.  Some  blood  may  be  present  in  the  urine  in  association 
M'ith  the  pyelitis,  but  an  acute  nephritis  is  seldom  seen,  al- 
though albuminuria  of  a  "febrile"  and  transitory  kind  is 
frequently  present.  Pleurisy  is  met  with  fairly  often,  some- 
times accompanied  by  sero-sanguinolent  fluid  effusion, 
and  occasionally  resulting  in  empyevia,  which  may  or 
n\ay     not     be      due     to     the      B.      typhosus.  A      some- 

what rare  but  alarming  complication  is  hcemorrhagic 
infarction  of  the  lung,  due  probably  to  throm- 
bosis occurring  in  the  right  heart  with  subsequent  embolism, 
or  to  the  formation  of  a  large  thrombus  in  the  pulmonary 
artery.  It  may  also  be  due  to  an  embolus  carried  from  a 
thrombosed  vein  in  the  leg  or  elsewhere.  The  infarction  is 
accompanied  by  more  or  less  sero-sanguinolent  effusion  into 
the  pleural  sac,  and  has  been  known  to  result  in  an  empyema. 
The  signs  of  the  infarction  are  sudden  pain  in  the  chest  or 
referred  to  the  abdomen,  limitation  of  thoracic  breathing,  some 
dullness  on  percussion  over  the  affected  area,  with  diminution 
in  the  volume  of  the  respiratory  murmur,  and,  very  soon  after 
the  occurrence,  the  auscultatory  signs  of  pleurisy  and  some  fine 
intrapulmonary  crepitus  with  distantly  tubular  breath- 
sounds  are  evident.    Sooner  or  later  after  the  occurrence  of  the 


Enteric    Fever.  23 

infarction,  the  sputum  is  tinged  witli  })lo()c],  sometimes  in  con- 
siderable quantity,  but  I  have  been  struck,  in  the  four  cases 
wbich  I  have  seen,  by  the  small  quantity  of  blood  present  and 
tbe  delay  in  its  appearance.  In  one  case  no  blood  appeared 
in  the  sputum  until  some  five  days  had  elapsed  after  the  in- 
farction had  occurred.  Of  the  four  cases  under  my  own 
observation  two  died,  one  having  been  operated  on  in  mistake 
for  perforation  of  the  intestine,  the  other  after  the  occurrence 
of  an  empyema  from  which  pure  cultures  of  the  B.  typhosus 
were  obtained.       The  other  two  cases  made  a  good  recovery. 

Peripheral  Neuritis  is  sometimes  met  with,  usually  in- 
dicated only  by  persistent  pain  in  the  heels  or  toes  whicli  may 
last  until  tlie  patient  has  completely  recovered  in  other 
respects.  The  '"tender  toes  of  typhoid"  are  familiar  and 
troublesome  results  of  the  fever  and  appear  late  in  the  period 
of  declension  or  during  convalescence.  Peripheral  neuritis 
of  a  more  serious  kind  is  occasionally  met  with,  resulting  in 
"dropped  wrist''  or  "dropped  ankle,"  and  once,  in  the  case  of 
a  medical  man,  I  have  seen  a  double  ulnar  palsy  which  per- 
sisted for  months. 

Endocarditis  is  a  very  rare  complication,  but  it  does 
sometimes  occur  and  may  be  followed  by  infarction  of  the 
kidney  or  spleen. 

Sequelae.  — The  sequelae  of  enteric  fever  are  such  as  might 
be  expected  from  a  long  febrile  illness  associated  with  a 
Special  lesion  of  the  intestine.  It  is  common  for  the  patient 
to  complain  for  many  months  after  his  illness,  of  distension 
of  the  abdomen  and  flatulence,  associated  with  some  pain  in 
the  right  iliac  region.  Combined  with  or  apart  from  this  he 
often  gives  evidence  of  marked  neurasthenia  long  after  con- 
valescence has  been  thoroughly  established.  He  is  physically 
weak,  and  easily  tired  mentally.  He  shirks  his  work,  avoids 
meeting  people,  is  afraid  of  various  things,  and  may  show  a 
tendency  to  melancholia. 

In  a  few  cases  which  I  have  seen,  this  neurasthenic  condi- 
tion combined  with  considerable  abdominal  discomfort  has  led 
the  patient  to  resort  to  alcohol  and  drugs  to  relieve  his  depres- 
sion,  with  the  result  that   a   previously  temperate   man   has 


24  Chaper  11. 

become  a  confirmed  alcoholic  or  drug-maniac.  Post-enteric 
neurasthenia  is  confined  to  no  particular  age  or  sex.  Chil- 
dren, adolescents,  and  adults  of  all  ages,  male  or  female,  may- 
fall  a  victim  to  this  extremely  troublesome  disorder. 

Typhoid  Spine. —  This  condition  is  comparatively  un- 
common, and  was  described  by  Gibney  in  1889  as  a  painful 
affection  of  the  spine  with  exaggerated  knee-reflexes,  ap- 
pearing towards  the  end  of  an  attack  of  enteric  fever  or  during 
convalescence. 

Pain  is  the  most  prominent  symptom,  and  is  felt  in  the 
lower  dorsal  and  lumbar  region,  extending,  in  some  cases, 
round  the  body  and  down  the  legs.  It  is  often  associated  with 
tenderness  over  one  or  two  vertebral  spines,  and  some  swelling 
of  the  adjacent  soft  tissues  is  not  uncommon.  In  one  case, 
reported  by  Ogilvy  in  the  Journal  of  the  American  Medical 
Association,  vol.  li,  p.  406,  the  swelling  and  tenderness  ex-* 
tended  on  both  sides  of  the  spine  over  practically  the  whole  of 
the  dorsal  region.  Areas  of  hypertesthesia  are  frequently  met 
with  on  one  or  other  side  of  the  tender  spot. 

Kyphosis  and  scoliosis  have  both  been  observed  in  con- 
nection with  this  condition. 

Walking  is  difiicult  and  increases  the  pain.  Paresis  of 
the  legs  is  sometimes  met  with,  and  the  patient  may  suffer 
from  spasm  and  cramp  and  even  wasting  of  the  leg  muscles. 

The  spine  is  sometimes  fixed  and  rigid,  and  in  some 
cases  the  slightest  movement  of  the  patient,  and  even 
of  his  bed,  will  induce  a  severe  attack  of  pain  in  the  back. 

Slight  fever  is  frequently  present  when  the  condition 
makes  its  appearance  during  convalescence. 

The  patient  who  suffers  from  typhoid  spine  is  often  the 
subject  of  a  general  neurosis,  and  may  be  hysterical,  imagina- 
tive, and  uncontrolled  in  many  ways,  even  though  his  pre- 
vious history  has  not  shown  any  indication  of  a  neurasthenic 
habit.  In  some  cases,  of  course,  the  patients  have  always 
been  neurotic  and  fanciful. 

The  onset  of  the  condition  is  usually  during  convalescence, 
being  seldom  delayed  longer  than  three  months  after  the 
attack    of    enteric    fever   has    subsided,    and    most    commonly 


Enteric    Fever.  25' 

appearing  just  as  tlie  patient  beg'ins  to  move  about.  The  dura- 
tion varies  from  a  week  or  two  to  many  months,  but  recovery 
is  practically  invariable. 

The  cause  of  typhoid  spine  is  probably  not  always  tlie 
same. 

In  certain  cases  described  by  Osier  it  would  appear  to 
be  the  result  of  a  neurosis,  and  in  such  cases  the  temperature 
and  pulse  are  not  abnormal,  and  paraplegia  of  a  definitely  Hys- 
terical type  may  be  present;  fleeting  disturbances  of  sensation, 
and  pain  in  tbe  back,  without  any  indication  of  gross  spinal 
lesion  or  disease  of  the  vertebral  column,  are  observed,  while- 
signs  of  a  general  neurotic  or  neurasthenic  state  may  be 
apparent. 

In  another  group  of  cases  there  is  definite  evidence  of 
perispondylitis  and  spondylitis,  evidenced  by  kyphosis  or 
scoliosis,  tenderness  and  pain  over  one  or  more  vertebrae,  and 
swelling  of  the  soft  parts  in  their  neighbourhood.  In  some 
cases  a  definite  formation  of  new  bone  has  been  observed  in 
connection  with  the  spondylitis. 

Typhoid  spine,  therefore,  would  appear,  from  the  writings 
of  Gibney,  Osier,  McCrae  and  others,  to  be  a  name  given  to 
a  set  of  symptoms  in  variable  combination,  of  which  the  most 
constant  is  pain  in  the  back,  usually  associated  with  some 
weakness  in  the  legs,  stiffness  in  the  back,  and  exaggerated 
knee-reflexes,  due  either  to  the  post-enteric  neurasthenic  state 
or  to  a  definite  perispondylitis  or  spondylitis  in  the  lower 
dorsal  and  lumbar  regions. 

Care  must  be  taken  in  arriving  at  a  diagnosis  of  typhoid 
spine  to  exclude  the  even  rarer  conditions  of  focal  myelitis- 
and  spinal  ineningitis  which  may  be  associated  with  exaggera- 
tion of  the  knee-reflexes  and  a  plantar  reflex  of  the  extensor 
type,  without  there  being  any  affection  of  the  sphincters  of 
the  bladder  and  rectum.  It  must  be  remembered,  also,  that 
an  insular  sclerosis  has,  in  one  or  two  cases,  followed  on  an 
attack  of  enteric  fever. 

Diagnosis. — The  diseases  most  likely,  from  their  general 
symptomatology  and  course,  to  be  confounded  with  enteric 
fever  are  abdominal  and  general  tvherculosis,  tuberculous 
meningitis,  irregular  forms  of  malaria,  low  forms  of  broncho- 


26  Chapter  II. 

'pneuTTionia,  acute  pneumonia  of  the  upper  lobe,  typhus  fever, 
influenza,  and  paratyphoid  fever.  It  is  only  during  tlie  first 
week  or  ten  daj's  that  acute  lobar  pneumonia  with  concealed 
physical  signs  is  likely  to  give  rise  to  a  suspicion  of  enteric 
fever,  and  then  the  mistake  in  diagnosis  is  usually  made  more 
from  insufficient  examination  of  the  chest  than  from  any  real 
simulation  of  enteric  fever  bj^  the  pneumonia.  The  differential 
diagnosis  between  typhus  and  enteric  is  often  difficult  during 
the  first  ten  days  of  acute  illness,  but  as  a  rule  the  types  of 
the  disease  are  distinct  and  separate,  the  flushed  dusky  face 
with  blood-shot  eyes  of  the  typhus  patient  contrasting  strongly 
wdth  the  pale  face,  malar  flush  and  clear  eye  of  enteric 
fever.  But  in  enteric  fever  the  face  may  be  sometimes 
flushed  and  dusky  at  an  early  stage,  the  delirium  may  simu- 
late that  of  typhus,  the  eye  may  be  bloodshot  and  suffused 
rather  than  clear,  and  the  differential  diagnosis  may  depend 
on  one  or  other  of  the  special  methods  available  for  the  diag- 
nosis of  enteric  fever. 

Careful  examination  of  the  blood  will  usually  exclude 
malaria,  as  it  is  rare  to  have  a  case  of  ague,  however  aberrant 
the  type  may  be,  in  which  the  infecting  organism  cannot  be 
discovered  by  those  to  whom  the  technique  of  examination  is 
familiar. 

For  the  differentiation  of  enteric  fever  from  tuberculous 
affections  one  depends  clinically  on  the  development  and  the 
course  of  the  disease,  on  the  occurrence  of  definite  special 
symptoms  and  the  application  of  certain  tests.  The  occur- 
rence of  squint  or  other  evidence  of  palsy  of  the  external 
muscles  of  the  eye,  double  vision,  or  failing  sight  will  often 
make  it  clear  that  a  doubtful  case  has  been  a  somewhat 
obscure  example  of  tuberculous  meningitis.  Enlargement  of 
the  abdomen  with,  perhaps,  signs  of  fluid  or  a  "doughy" 
feeling  on  manipulation  or  with  deflnite  distension  of  the  ab- 
dominal veins,  will  indicate  a  tuberculous  laeritonitis,  and  the 
discovery  of  tubercle  bacilli  in  the  sputum  will  lead  to  the 
diagnosis  of  pulmonary  phthisis,  especially  if  the  patient  has 
not  been  in  very  good  health  before  the  onset  of  the  symptoms 
which  have  led  to  his  coming  under  observation.     Of  course, 


Enteric   Fever.  27 

it  is  possible  that  a  patient  suffering  from  phthisis  may  con- 
tract enteric  fever,  and  it  is  therefore  wise  to  make  special 
examination  of  the  blood  for  signs  of  enteric  fever  in  all  cases 
Avhere  the  diagnosis  is  doubtful,  a))d,  wliere  there  seems  to  be  a 
possibility  of  some  tuberculous  mischief  being  present,  to 
perform  Calmette's  or  von  Pirquet's  tests,  or  give  a  test  injec- 
tion of  tuberculin. 

Paratyphoid  fever  is  practically  similar  in  its  manifesta- 
tions to  a  mild  attack  of  enteric  fever,  and  a  purely  clinical 
differentiation  is  impossible.  Its  diagnosis  must  depend  on 
the  absence  of  an  agglutinative  reaction  with  the  B,  typhosus 
and  the  presence  of  an  agglutinative  reaction  with  the  B. 
paratyphosus,  or  on  the  recovery  of  the  B.  paratyphosus  from 
the  blood.  The  methods  of  cultivating  the  B.  paratyphosus 
are  similar  to  those  employed  in  the  cultivation  of  the  B. 
typhosus,  and  the  differences  in  the  two  organisms  are  brought 
out  by  subculture  on  various  media,  as  will  afterwards  be 
described.  The  bacilli  can  also  be  tested  with  serum  which 
is  known  to  have  the  power  of  agglutinating  the  B.  typhosus. 

llie  blood  in  enteric  fever  shows  as  a  rule  a  fall  in  the 
number  of  white  cells  to  below  the  normal.  On  the  occurrence 
of  perforation  or  general  peritonitis  from  any  cause  a  poly- 
morphoneuclear  leukocytosis  often  occurs,  but  not  invariably, 
while  a  leukocytosis  may  occur  in  connection  with  a  pleurisy 
with  effusion,  an  empyema,  or  any  suppurative  condition. 

The  special  diagnostic  methods  of  greatest  service  in  the 
diagnosis  of  enteric  fever  are  the  bacteriological  examination 
of  the  blood  and  Widal's  agglutination  test.  WidaVs  re- 
action depends  on  the  power  of  the  blood-serum  of  a  patient 
suffering  from  enteric  fever  to  agglutinate  living  motile  cul- 
tures of  the  B.  typhosus  in  large  dilution  and  in  a  short  time. 
The  degree  of  dilution  of  the  serum  is  important,  as  in  cer- 
tain other  diseases  the  serum  from  the  patient  will  agglutinate 
cultures  of  the  B.  typhosus  if  the  dilution  is  small  and  the 
serum  be  left  in  contact  with  the  bacilli  for  a  long  time.  It 
is  my  practice  to  perform  the  test  with  blood-serum  diluted 
60-100  times  with  an  emulsion  of  a  young  culture  of  B. 
typhosus  in  sterile  salt  solution,  and  if  satisfactory 
clumping    does    not    take    place    within    forty-five    minutes 


28  Chapter  II. 

to  an  hour,  to  coiisidei'  the  reaction  negative.  With 
these  precautions  the  test  is  often  of  the  greatest 
service,  but  it  is  to  be  remembered  that  an  agglutina- 
tive reaction  is  seldom  obtained  earlier  than  the  eighth 
or  tenth  day  and  may  not  appear  until  convalescence  is  well 
established,  so  that  a  negative  result  cannot  of  itself 
exclude  enteric  fever.  As  a  rule,  however,  the  reaction 
can  be  obtained  after  the  first  eight  or  ten  days  of  the  disease. 
Other  diseases  in  which  Widal's  reaction  may  be  obtained  are 
general  tuberculosis  and  typhus,  and  occasionally  the  reaction 
is  present  in  these  diseases  even  after  the  serum  has  been  well 
diluted.  It  is  unfortunate  that  these  are  two  of  the  verv 
diseases  which  are  frequently  difficult  to  distinguish  from 
enteric  fever. 

Of  far  greater  value  in  the  early  diagnosis  of 
enteric  fever  is  the  making  of  a  culture  from  the  blood.  10-20 
c.c.  of  blood  is  drawn  from  a  vein  with  proper  aseptic  pre- 
cautions, citrated,  placed  in  peptone  bouillon  after  long  cen- 
trifugalisation  in  sterile  tubes,  and  incubated  at  37°  C,  and 
the  resulting  growth  examined  for  the  B.  typhosus. 

If  an  organism  is  present  which  has  the  morphological 
characters  of  the  B.  typhosus,  subcultures  must  be  made  on 
differentiating  media  to  make  sure  that  it  is  the  B.  typhosus 
and  not  the  B.  paratyphosus.  Media  containing  glucose  or 
dulcite  coloured  with  neutral  red,  and  milk  containing  litmus 
are  of  most  service.  The  B.  typhosus  forms  acid  without  gas 
with  glucose;  the  B.  paratyphosus  forms  both  acid  and  gas. 
With  dulcite,  the  B.  typhosus  forms  neither  acid  nor  gas; 
the  B.  paratyphosus  forms  both.  After  three  days'  incuba- 
tion at  37°  C.  in  litmus  milk,  the  B.  typhosus  shows  the  pro- 
duction of  acidity,  and  the  B.  paratyphosus  the  development 
of  alkalinity. 

The  results  are  conveniently  shown  in  the  form  of  a 
table : — 


Glucose.  Dulcite.        Litmus  Milk. 

3  days. 

B.  Typhosus I       Acid.  —  Acidity. 

B.  Pabatyphqsus       Acid  &  Gas.     Acid  &  Gas.  ;    Alkalinity. 


Enteric   Fever.  29 

This  differentiation  can  be  done  by  any  one  who  has  had 
a  good  bacteriological  training  and  possesses  an  incubator,  but 
both  the  blood  culture  and  Widal's  test  are  better  done  by  a 
bacteriologist  in  connection  with  the  Public  Health  adminis- 
tration of  the  district  or  one  of  the  large  Clinical  Laboratories. 
In  many  places  such  examinations  are  made  by  the  municipal 
bacteriologist. 

The  diazo-reaction  of  Ehrlich  is  of  little  value  in  the 
differential  diagnosis,  and  is  but  rarely  used  now. 

Puncture  of  the  spleen  for  the  recovery  of  the  B. 
typhosus  has  been  done  occasionally,  but  this  procedure  is  not 
to  be  recommended,  as  the  typhoid  spleen  is  soft  and  the  re- 
sulting haemorrhage  may  be  severe,  and  even  fatal.  The 
operation,  too,  is  painful  and  may  induce  shock. 

RelaiJses  are  very  common  in  enteric  fever. 

The  temperature  may  run  a  typical  course,  with  a  fasti- 
gium  of  average  or  more  than  average  length,  and  a  lysis  of 
considerable  duration,  yet  after  it  has  remained  normal  for 
periods  varying  from  one  to  ten  or  twelve  days  it  may  again 
rise  gradually  and  the  patient  embarks  on  what  is  practically 
a  second  attack  of  the  fever,  including  the  eruption  of  rose- 
spots.  E-elapse  may  occur  after  a  primary  attack  of  great 
severity  and  long  duration,  and  also  after  an  attack  which 
has  been  very  mild  indeed.  As  a  general  rule  a  relapse  is 
milder  than  the  primary  attack,  but  to  this  rule  there  are 
many  exceptions,  and  a  severe,  and  even  fatal,  relapse  may 
follow  a  primary  attack  so  mild  as  to  be  almost  "ambulatory" 
in  type.  It  is  unusual  to  meet  with  any  of  the  graver  com- 
plications of  enteric  fever  in  the  course  of  a  relapse,  but  they 
do  occur,  particularly  where  the  primary  attack  has  been  mild 
and  the  subsequent  relapse  severe.  Sometimes  several  re- 
lapses follow  the  primary  attack,  and  the  severity  of  each  of 
these  is  usually  much  less  than  its  predecessor.  Four  relapses 
is  the  greatest  number  which  I  have  seen,  but  more  have  been 
recorded.  Each  relapse  is  separated  from  its  successor  by  at 
least  a  few  days  of  normal  temperature.  The  term  recrude!^- 
cence  is  used  to  describe  the  condition  when  the  temperature 
begins  to  rise  again  after  the  lysis  has  commenced,  but  where 


30  Chapter  11. 

the  curve  has  not  reached  normal.  The  distinction  between 
relapse  and  recrudescence  is  purely  arbitrary. 

Treatment.  —  In  considering  the  treatment  of  enteric 
lever  ■  we  must  remember  that  we  are  dealing  with  a 
prolonged  febrile  disease  in  which  wasting  is  a  prominent 
feature,  in  which  the  fever  often  runs  high,  which  may  be 
attended  with  profound  toxtemia,  and  which  may  show  various 
complications  that  call  for  special  treatment. 

In  no  acute  fever,  save,  perhaps,  pneumonia  and  diph- 
theria, is  the  necessity  for  absolute  physical  and  mental  rest 
so  urgent  as  in  enteric  fever,  not  only  from  the  necessity  for 
husbanding  in  every  way  the  patient's  strength,  but  also 
because  movement  may  prejudice  the  local  lesion  in  the  in- 
testine and  encourage  haemorrhage  or  perforation.  It  is  the 
custom  in  this  country  to  insist  on  the  use  of  the  bed-pan  and 
bed-urinal,  although  in  mild  constipated  cases  it  may  be 
no  disadvantage  to  allow  the  patient  to  get  up  to  stool  if  the 
night-chair  is  placed  close  to  the  bed  and  he  is  not  allowed  to 
walk. 

If  constipation  is  present,  the  bowels  should  be  moved 
at  least  every  second  day  by  soap  and  water  enemata,  unless 
the  calomel  treatment  is  adopted,  and  flatulent  distension  may 
be  greatly  relieved  by  an  injection  of  olive  oil  and  turpen- 
tine. Where  flatulent  distension  is  troublesome,  the  applica- 
tion of  tepid  compresses  to  the  abdomen  every  four  hours  or 
oftener,  for  fifteen  minutes  at  a  time,  may  give  great  relief. 
Frequent  and  troublesome  diarrhoea  is  often  controlled  by  the 
introduction  of  a  long  colon-tube  and  gentle  but  free  in'i- 
gation  of  the  lower  bowel  with  warm  water. 

The  patient  should  be  washed  all  over  daily  with  soap 
and  water.  The  skin  of  the  back,  especially  over  the  buttocks 
and  sacrum,  should  be  sponged  several  times  in  the  day  with 
methylated  spirit  and  carefully  powdered  with  a  dusting- 
mixture  of  equal  parts  of  powdered  starch,  boric  acid  and 
lycopodium,  to  prevent  the  occurrence  of  bed-sores  which 
should  never  be  seen  in  a  carefully  tended  patient.  Great 
care  should  be  taken  to  change  the  position  of  the  patient  fre- 
quently, both  to  avoid  bed-sores  and  to  prevent  as  far  as 
possible  the  development  of  hypostatic  congestion  of  the  lungs. 


Enteric   Fever.  31 

In  profoundly  toxic  cases  the  injection  of  a  pint  of  hot 
sterile  salt  solution  into  the  subcutaneous  areolar  tissue  is 
often  productive  of  good  results. 

Headache  may  be  relieved  by  the  application  to  the  fore- 
head of  cloths  dipped  in  cold  water  and  vinegar.  It  is  best 
to  avoid  giving  phenacetin  as  it  is  rather  depressing,  but 
the  citrate  of  calfein  is  effective  in  doses  of  five  grains  repeated 
every  few  hours,  and  the  use  of  the  bromides  is  often  followed 
by  excellent  results. 

Delirium  and  restlessness,  even  apart  from  excessive 
fever,  are  best  treated  by  cold  applications  to  the  skin,  either 
by  means  of  sponging,  compresses  or  baths,  but  it  may  be 
necessary  to  use  opium  or  other  hypnotics  to  quiet  the  patient 
and  induce  sleep.  It  must  be  remembered  that  patients  suf- 
fering from  enteric  fever  bear  opium  badly,  and  that  even  in 
moderate  doses  it  tends  to  induce  meteorism.  If  it  is  used  at 
all,  it  should  be  given  in  small  doses,  5-10  minims  of  Battley's 
solution  or  ISTepenthe  by  the  mouth,  combined,  it  may  be,  with 
five  grains  of  chloral  hydrate  or3ss  of  the  Syrup  of  Chloral, 
or  the  hypodermic  injection  of  morphine,  gr.  \,  may  be  em- 
ployed. Such  doses  of  opium,  alone  or  in  combination,  may 
be  repeated  every  three  or  four  hours  until  the  patient  is 
quiet  or  until  it  is  evident,  after  some  half-dozen  doses,  that 
the  treatment  is  of  no  avail.  Veronal,  trional,  or  sulphonal 
in  doses  of  ten  grains  in  ^ss-^i  of  whisky  with  hot  water 
and  a  little  sugar  sometimes  act  very  well  and  induce  sleep 
after  two  or  three  doses  at  intervals  of  two  hours  have  been 
given.  Occasionally  I  have  seen  sleep  produced  and  violent 
delirium  quieted  by  paraldehyde  in  doses  of  90  minims  re- 
peated at  intervals  of  an  hour  till  three  doses  have  been 
taken.  Sometimes  §i  or  §ii  of  whisky  with  hot 
water  and  sugar  given  in  the  evening  will  induce  sleep  in  a 
patient  who  is  just  beginning  to  show  signs  of  restlessness  and 
who  has  not  been  relieved  by  cold  or  tepid  sponging. 

It  may  be  necessary  to  reduce  the  temperature  if  it  be  at 
all  high,  say  above  103^  F.,  and  the  patient  is  restless  and 
uncomfortable.  No  antipyretic  drugs  should  be  used  for  this 
purpose,  but  the  temperature  can  often  be  reduced  by  2°  F.  or 
more  by  cold  sponging,  by  a  cold  compress  applied  to  the 


32  Chapter  II. 

front  of  the  body  from  neck  to  knees  and  changed  every  two 
or  three  minutes;  by  rubbing  the  surface  of  the  body  with  a 
block  of  ice;  or  by  the  use  of  the  cold  or  tepid  bath.  The 
bath  is  excellent  for  Hospital  use,  but  is  almost  impracticable 
in  private  practice,  as  a  large  portable  bath,  capable  of  hold- 
ing an  adult  patient  stretched  at  full  length,  is  necessary. 
This  inconvenience  is  the  only  valid  argument  against  the  in- 
telligent use  of  the  bath,  which  should  be  kept  at  a  tempera- 
ture of  about  80°-90°  E.  during  the  immersion.  In  careful 
hands  no  harm  should  result  from  the  manipulation  of  the 
patient,  and  fever  and  restlessness  which  have  not  yielded  to 
any  other  form  of  treatment  may  yield  to  this.  But  in 
private  practice  nearly  as  good  results  are  obtained  from  the 
use  of  the  cold  compress  applied  from  neck  to  knees,  changed 
every  minute  or  two  and  repeated  until  a  fall  of  temperature 
of,  say,  2°  F.  has  been  produced.  If  this  fails,  it  is  com- 
forting to  remember  that  in  certain  cases  the  fever  will  not 
yield  even  to  repeated  cold  baths,  but  continues  to  rise,  or  at 
least  to  remain  stationary  at  a  very  high  level,  in  spite  of  all 
the  efforts  of  the  physician.  When  this  occurs  it  is  plain 
that  we  are  dealing  with  a  peculiarly  virulent  form  of  the 
disease,  probably  a  fulminant  type  that  will  kill  whatever 
'endeavours  we  may  make  towards  its  cure.  It  is  interesting 
to  observe  that  a  great  reduction  of  temperature  is  not  neces- 
sary to  ensure  marked  improvement  in  the  patient's  condition. 
'The  reduction  of  the  temperature  by  1°  or  2°  F.  is  usually  suffi- 
cient to  produce  a  feeling  of  comfort  and  quiet  in  the  patient 
-and  to  induce  sleep,  even  if  only  for  a  short  time.  It  is  not 
wise  by  prolonged  exposure  to  cold  applications  to  reduce  the 
temperature  to  the  neighbourhood  of  normal  at  the  expense  of 
"the  patient's  comfort  and  strength,  as  is  so  often  done.  To 
put  it  broadly,  the  temperature  should  be  reduced  as  little  as 
possible,  compatible  with  the  comfort  of  the  patient,  save 
when  grave  hyperpyrexia  is  present.  A  fall  of  2°  F.  accom- 
panied with  comfort  is  better  than  a  fall  of  4°  F.  accompanied 
by  a  feeling  of  prostration  and  faintness  on  the  patient's  part. 
The  relief  from  high  fever  is  only  temporary  and  the  cold  ap- 
plications may  have  to  be  frequently  repeated  before  the 
general  course  of  the  temperature  returns  to  moderate  levels. 


Enteric  Fever.  3.3 

The  "swinging"  type  of  temperature  vvliich  is  often  met 
with  at  the  period  of  declension  is  sometimes  attended  by 
rigors  while  the  temperature  is  rising  and  collapse  when  the 
temperature  falls.  The  patient  must  be  kept  warm  under  these 
conditions;  hot  bottles  or  sand-bags  should  be  placed  at  the 
feet  and  along  the  sides,  and  hot  cloths  applied  over  the  heart. 
Quinine  in  doses  of  10  grains  is  said  by  some  to  influence  this 
type  of  fever,  but  I  have  never  seen  any  good  come  of  its 
use. 

Strychnine  is  sometimes  of  service  when  there  is  a 
tendency  to  meteorism,  and  is  best  given  hypodermically  in 
doses  of  o't)^^^  of  ^  grain  repeated  every  four  liours.  This 
ma 3'  be  continued  for  several  days  at  a  time.  When  the 
pulse  is  unduljr  rapid  and  soft,  digitalis  should  be  given,  and 
if  given  at  all  the  dose  should  be  fairly  large.  I  have  ob- 
tained the  best  results  with  Nativelle's  granules  of  crystalline 
digitalin,  giving  one  every  three  or  four  hours,  but  10  minims 
of  a  reliable  tincture  given  every  two  hours  until  an  effect  on 
the  heart  is  produced  or  nausea  and  diarrhoea  occur  is  less  ex- 
pensive and  practically  as  rapid  in  action.  It  frequently 
happens,  however,  that  digitalis  has  no  effect  in  slowing  the 
pulse,  and  if  any  signs  of  digitalis  poisoning  appear,  it  is  wise 
to  discontinue  the  use  of  the  drug,  although  the  effect  on  the 
patient  of  slight  poisoning  by  digitalis  has  been  greatly 
exaggerated. 

It  has  been  usual  to  give  alcohol  as  a  stimulant  in  cases 
with  soft  rapid  pulses  and  a  tendency  to  other  signs  of  heart- 
failure,  and  it  may  be  of  great  value  in  promoting  a  sense  of 
well-being  in  the  patient,  but  if  given  at  all  it  should  be  used 
in  small  doses,  Jii-O^^i  ^^  ^  time,  repeated  every  two  or 
three  hours,  and  not  more  than  §iv  should  be  given  in  the 
day.  If  it  be  found  that  under  the  influence  of  small  doses  of 
alcohol  the  pulse-rate  does  not  fall  and  restlessness  is  not 
lessened  after  twenty-four  hours,  the  advisability  of  discon- 
tinuing the  treatment  should  be  considered. 

The  use  of  purgatives  in  enteric  fever  has  been  the  sub- 
ject of  much  discussion,  and  it  is  necessary,  in  this  connection, 
to  consider  the  stage  of  the  disease  at  which  the  patient  has 
arrived.     If  the  disease  is  in  a  very  early  stage,  say  in  the 

D 


34  Cliayter  II. 

first  week,  when  diagnosis  is  in  doubt,  it  is  not  wise  to  with- 
hold a  smart  purgative,  such  as  two  or  three  grains  of  calomel 
or  a  table-spoonful  of  castor  oil,  or  a  pill  containing  Pil. 
Hydrarg.  grs.  ii,  Pil.  Colocynth.  et  HyOiScyami  grs.  iii,  with 
Extract.  Belladonnas  gr.  \,  followed  by  a  saline  aperient 
draught  in  the  morning,  simply  on  the  suspicion  that  the  un- 
known fever  may  turn  out  to  be  enteric,  since  at  that  early 
stage  of  the  disease  a  single  dose  of  this  kind  may  be  given 
with  advantage  even  in  enteric  fever.  On  the  other  hand,  if 
the  diagnosis  of  enteric  fever  has  been  made,  frequent  purga- 
tion by  means  of  salines,  Cascara  Sagrada,  aloes,  or  powerful 
mercurials  is  to  be  strongly  discouraged,  as  the  throwing  of 
the  intestine  into  a  considerable  degree  of  peristalsis  or  greatly 
increasing  the  fluidity  of  the  stools  by  action  on  the  intes- 
tinal mucous  membrane  is  bad  practice  in  view  of  the  local 
lesion.  But  the  present  habit  which  most  generally  prevails, 
of  moving  the  bowels  only  by  enemata,  has  become  a  little  too 
fixed  in  the  practice  of  many  physicians.  Small  doses  of 
castor  oil,  repeated,  if  necessary,  more  than  once  in  the  day, 
are  quite  permissible  if  they  do  not  cause  nausea  or  griping, 
while  I  have  seen  good  results  from  the  giving  of  small  doses 
of  calomel  continued  steadily  for  some  days  or  even  weeks, 
during  the  height  of  the  fever.  I  do  not  believe  that  the  use 
of  calomel  shortens  the  course  of  the  disease  to  any  great  ex- 
tent, but  in  cases  treated  by  calomel,  meteorism  and  ab- 
dominal discomfort  are,  I  think,  less  common  than  in  cases 
treated  only  by  enemata. 

The  calomel  treatment  of  enteric  fever  is  best  carried  out 
as  follows: — Calomel,  gr.  \,  combined  with  Resin  of  Podo- 
phyllin,  gr.  ^-Vj  may  be  given  every  hour  during  the 
waking  time  of  the  day,  so  that  some  2  grains  of  Calomel  and 
gr.  I"  of  Podophyllin  are  taken  in  the  twenty-four  hours. 
This  should  be  continued  steadily  for  3  or  4  days  and  then  be 
discontinued  for  tweny-four  hours.  At  the  end  of  each  day  of 
calomel  treatment  tlie  lower  bowel  should  be  gently  irrigated 
with  warm  water  to  ensure  its  complete  emptying.  The  irriga- 
tion should  be  done  by  means  of  a  douche-can  and  a  soft  india- 
rubber  tube  with  a  rubber  catheter  attached.  The  patient 
should  lie  on  the  left  side  and  have  his  hips  slightly  raised. 


Enteric   Fever.  35 

The  water  must  be  boiled  and  should  be  at  a  temperature  of 
112°  F.  at  the  commencement  of  the  irrigation,  us  tepid  or  cold 
water  is  apt  to  induce  collapse.  Tlie  patient  should  be  put  on 
Chlorate  of  Potash,  grs.  5,  every  four  hours  during  the  resting 
period,  and  at  the  end  of  twenty-four  hours  the  calomel  sliould 
be  recommenced  .  This  method  of  treatment  by  calomel  seemis 
to  have  no  evil  result  on  the  local  lesion  (perforation  is  rather 
less  common  in  cases  treated  thus,  and  haemorrhages  are  no 
more  common),  but  it  is  perhaps  wise  to  give  no  purgatives, 
even  calomel,  if  the  third  week  of  the  disease  has  been  entered 
upon  before  the  patient  comes  under  observation.  I  have 
begun  the  use  of  calomel  in  small  doses  in  the  third  week 
without  any  untoward  result,  but  I  do  not  recommend  the 
practice.  No  other  purgative  should  be  given  in  the  third 
week. 

The  effect  of  the  repeated  small  doses  of  calomel  is  to  in- 
duce without  pain  free  and  frequent  movement  of  the  bowels, 
4-5  stools  in  the  day  at  the  end  of  the  first  two  days  treat- 
ment being  common,  with  a  reduction  to  two  or  three  later 
on. 

The  tongue  grows  cleaner,  and  there  is  seldom  any  ab- 
dominal discomfort  or  distension  in  patients  treated  in  this 
way,  and  I  believe  that  under  this  treatment  patients  assimi- 
late better,  relapses  are  less  frequent,  and  convalescence 
more  rapid  and  complete,  than  when  the  bowels  are  moved 
merely  by  enemata. 

Diet. — This  should  at  first,  until  the  fastigium  is  prac- 
tically over,  be  absolutely  fluid,  save  in  certain  cases  which  I 
shall  mention  later.  Water  should  be  given  freely,  in  small 
quantities  of  §ii  or  §iii  at  a  time,  frequently  repeated.  Milk, 
plain,  flavoured  with  coffee  or  tea  and  sweetened,  or  diluted 
with  warm  water  or  barley  water  and  slightly  salted,  should 
form  the  staple  diet.  But  it  is  well  to  give  some  clear  soup  in 
addition,  to  the  extent  of  a  pint  in  the  twenty-four  hours,  and 
if  thirst  is  excessive,  water  with  a  few  minims  of  dilute  Nitro- 
hydrochloric  acid  and  flavoured  with  lemon  is  sometimes  of 
great  service.  If  there  is  a  tendency  for  curd  to  be  passed  in 
the  stools.  Sodium  Citrate  should  be  added  to  the  milk  to  the 
amount  of  5  grs.  to  the  ounce.     This  "citrated  milk"   often 

D     '2 


36  Chapter  II. 

makes  milk  feeding  well  borne  by  patients  who  have  been 
previously  intolerant  of  it.  A  raw  egg  switched  into  milk  is 
a  useful  addition  to  the  day's  food,  and  is  to  be  recommended 
in  prolonged  cases  with  much  wasting  and  loss  of  strength. 
Milk  sugar  or  fine  white  cane  sugar  may  be  added  to  the  milk- 
feeds  in  such  quantities  as  may  be  most  pleasant  for  the 
patient.  The  importance  of  an  adequate  amount  of  carbohy- 
drate in  the  dietary  of  the  enteric  patient  cannot  be  too  much 
emphasised.  If  the  fastigium  be  well  advanced  and  the 
patient  is  really  hungry  and  shows  no  untoward  symptoms, 
small  quantities  of  a  well-cooked  pudding  of  milk  and  rice, 
or  milk  and  arrowroot,  may  be  given  twice  in  the  day.  This 
pudding  must  be  cooked  slowly  for  at  least  three  hours.  The 
detritus  from  such  food  is  practically  negligible  and  is  not 
likely  to  give  rise  to  any  accident.  If,  however,  it  be  found 
that  such  food  tends  to  produce  gastric  discomfort  or  ab- 
dominal distension  it  should  be  discontinued  for  a  day  or  two 
and  then  tried  again.  A  semi-solid  diet  of  this  kind  is 
satisfying  to  the  patient  and  helps  to  keep  the  mouth  clean. 
If  a  patient  can  be  trusted  to  masticate  thoroughly,  the  ad- 
dition of  a  piece  of  dry  bread  daily  to  his  diet  during  the 
period  of  declension  is  not  at  all  dangerous,  but  few  patients 
will  take  the  trouble  to  chew  it  almost  to  a  liquid  before 
swallowing  it,  and  it  is,  therefore,  wisely  avoided  in  most 
cases. 

Benger's  food,  Mellin's  food,  "AUenbury's  Diet,"  Soma- 
tose  and  Sanatogen,  are  all  useful  in  the  period  of  declension 
when  no  complication  has  interrupted  the  course  of  the  disease, 
but  I  greatly  prefer  the  first  three  to  the  more  purely  nitro- 
genous preparations. 

In  a  normal  uncomplicated  case  a  piece  of  dry  bread  may 
be  given  after  the  temperature  has  been  normal  for  seven  days. 
It  has  often  been  urged  that  this  is  too  early  a  date  to  begin 
feeding  as  it  so  often  happens  that  a  relapse  follows  on  the 
giving  of  food  on  the  Tth  or  8th  day  of  normal  temperature, 
but  I  have  noticed  that  relapses  beginning  on  the  7th  or  8th 
day  are  just  as  common  when  I  have  been  starving  patients 
till  the  14th  day  as  when  I  have  been  feeding  them  on  a  semi- 
solid diet  through  the  period  of  declension,  and  allowed  them 


Enteric   Fever.  37 

to  have  bread  on  the  8th  day,  the  fact  being  that  a  relapse 
occurs  naturally  about  that  time  with  great  frequency.  It  is 
often  wise,  if  the  patient  is  hungry  and  there  is  little  abdomi- 
nal distension,  to  feed  through  a  mild  relapse  with  semi-solid 
food,  especially  if  the  primary  attack  has  been  of  long  dura- 
tion and  the  nutrition  of  the  patient  is  low. 

After  the  patient  has  been  for  two  days  on  bread,  a  little 
steamed  white  fish  may  be  given,  by  preference  whiting;  and 
custard,  bread  and  butter  pudding,  toast  and  butter,  boiled, 
poached  or  scrambled  eggs,  may  be  added  gradually  during 
the  next  week  and  at  the  end  of  that  time  chicken,  or  pheasant 
if  it  is  in  season,  may  be  given,  followed  in  a  day  or  two  by 
a  lightly-grilled  chop.  After  the  temperature  has  remained 
normal  for  three  weeks  the  patient  may  be  permitted  to  get  up 
for  a  short  time  if  his  strength  permit,  and  an  ordinary  light 
mixed  dietary  gradually  resumed.  Alcohol  should  on  no 
account  be  allowed  to  a  convalescent  from  enteric  fever. 

The  treatment  of  Complications  needs  some  consideration. 
Perforation,  rupture  of  a  suppurating  Tnesenteric  gland, 
appendicitis  and  general  peritonitis  from  any  cause  demand 
immediate  operative  interference.  As  an  example  of  the 
results  afforded  now-a-days  by  laparotomy  in  general  peri- 
tonitis, I  append  the  details  of  operations  performed  by  Mr. 
Farquhar  Macrae,  during  the  last  ten  years,  in  the  Fever  Hos- 
pitals in  Glasgow,  and  furnished  to  me  by  him.  In  con- 
sidering these,  it  is  to  be  remembered  that  in  earlier  days 
these  complications  practically  always  ended  fatally,  and,  with 
improved  operative  technique  and  after-treatment,  especially 
since  the  introduction  of  the  semi-upright  position,  and  the 
stimulus  which  successful  operation  has  given  to  early  diag- 
nosis, the  results  are  steadily  improving.  It  is  as  wrong  to 
delay  operation  when  such  conditions  are  suspected  as  it  is  to 
treat  diphtheria  without  antitoxin. 

The  importance  of  early  diagnosis  on  the  part  of  the 
physician  cannot  be  too  greatly  emphasised,  as  everv 
hour's  delay  lessens  the  chance  of  successful  operation. 
Where  the  general  mortality-rate  of  an  outbreak  is  high,  the 
death-rate  in  cases  of  perforation  will  be  proportionately  as 


38  Chapter  11. 

liig-li  or  even  higher,  so  that  a  bad  run  of  cases  in  a  severe 
epidemic  must  not  prejudice  either  physicians  or  surgeons 
against  operation. 

The  following  table  shows  the  results  of  Macrae's  opera- 
tions in  general  peritonitis  complicating  enteric  fever,  up  to 
the  middle  of  December,  1910  :  — 

Cases,  Recoveries. 
Without  perforation  or  rupture  of  abscess     10         3 
With  rupture  of  mesenteric  gland-abscess       2         1 
With  rupture  of  an  abscess  in  the  spleen       1         1 
With  perforation  of  the  intestine    53       12 

Total 66       17 

In  all  thei  fatal  cases  of  general  peritonitis  occur- 
ring without  perforation  or  rupture  of  an  abscess,  the 
diagnosis  was  confirmed  by  post-mortem  examination,  ex- 
cept in  one  case,  when  permission  to  make  an  examination 
was  refused. 

Abscesses  in  the  subcutaneous  and  inter Tnuscular  areolar 
tissue  must  be  opened  and  dressed  antiseptically.  They  heal, 
as  a  rule,  slowly,  and  occasionally  occur  in  cases  which  ulti- 
mately die  of  asthenia.  Particular  attention  must  be  paid  to 
the  general  condition  of  patients  suffering  from  these 
abscesses. 

HceTnorrhage  jroitn  the  bowel  sufficiently  severe  to 
render  treatment  other  than  simple  rest  a  necessity  is  best 
treated  by  the  judicious  use  of  small  doses  of  opium,  by  the 
mouth  or  hypodermically,  by  the  hypodermic  injection  of 
repeated  small  doses  of  strychnine,  by  the  application  of  tepid 
compresses  to  the  abdomen  and  the  injection  of  a  pint  of 
physiological  salt-solution  into  the  subcutaneous  areolar 
tissue.  I  have  never  seen  any  good  come  of  the  use  of  lead, 
tannic  acid,  or  the  so-called  astringents,  or  of  the  administra- 
tion of  ergot,  ergotin,  or  suprarenal  extract.  Opium,  even 
though  it  may  have  no  direct  effect  on  the  haemorrhage,  is  of 
value  in  inducing  rest  and  sleep  and  in  lessening  peristalsis 
and  the  absorption  of  the  products  of  intestinal  fermentation. 
If  given  with  strychnine  it  does  not  unduly  relax  the  intestine 


Enteric   Fever.  39 

and  induce  ineteorism,  wliicli  one  particularly  wishes  U) 
avoid  in  such  cases.  Tepid  compresses  on  the  abdomen  seem 
to  have  some  action  in  restoring-  the  tone  of  the  gut,  and  are 
better  than  any  cold  applications,  since  the  surface 
temperature  is  lowered  and  a  patient  feels  chilly  if 
a  hemorrhage  is  at  all  large.  The  injection  of  a  pint  of 
physiological  salt-solution  into  the  subcutaneous  areolar  tissue 
is  of  service  in  two  ways,  it  dilutes  tlie  toxins  and  supplies 
fluid  to  the  blood  to  replace  that  lost  by  the  intestine.  The 
injection  may  be  repeated  several  times  if  thought  necessary. 
The  physiological  salt  solution  should  be  carefully  sterilised 
fund  allowed  to  run  in  by  siphon  action  at  a  temperature 
of  110°  F. 

Venous  tlirowljosis,  as  commonly  met  with  in  the  leg, 
necessitates  rest  of  the  part  affected  and  of  the  patient  generally. 
The  limb  should  be  elevated,  wrapped  in  gamgee  or  cottonwool 
after  the  skin  has  been  carefully  cleansed  with  soap  and 
water,  washed  with  spirit  and  powdered  with  a  dusting-mix- 
ture of  starch,  lycopodium  and  boric  acid,  in  equal  parts,  and 
lightly  bandaged  from  foot  to  hip.  Pain  should  be  relieved 
by  opium,  either  10-15  minims  of  Nepenthe  or  Battley's  solu- 
tion by  the  mouth,  or  \  gr.  of  morphine  hypodermically 
repeated  every  two  hours  until  relief  is  obtained. 

Lymphangitis  of  the  thigh  or  leg  must  be  treated  by  rest 
and  warmth,  and  by  the  painting  of  the  skin  over  the  in- 
guinal glands  with  tincture  of  iodine.  Pain  may  be  relieved 
by  the  application  to  the  limb  of  hot  compresses  spread  with 
the  glycerine  of  belladonna,  and  by  the  administration  every 
hour  of  one  or  two  minims  of  Battley's  solution  and  tincture  of 
belladonna  by  the  mouth. 

Cystitis  and  Pyelitis  due  to  the  B.  typhosus  rarely  give 
rise  to  much  pain  or  discomfort.  The  patient  should 
be  made  to  drink  large  quantities  of  fluid,  and 
TTrotropin  in  doses  of  5  grs.  every  three  or  four  hours  may  be 
given  with  advantage,  while  1  minim  doses  of  Tinct.  Bella- 
donnae  every  hour  will  lessen  pain  and  spasm. 


40  Chapter  11. 

Pleurisy  and  Ilcvmorrhagic  Infarction  of  tlie  Lung  are 
both  productive  of  discomfort  on  account  of  the  embarrass- 
ment to  respiration,  and  are  frequently  associated  with  severe 
pain. 

Opium  by  the  moiith,  or  the  hypodermic  injection  of  mor- 
phine should  be  used,  and  hot  fomentations  to  the  chest  wall 
either  simple  or  having  3^  ^^  Glycerine  of  Belladonna  or  of 
Tinct.  Opii  spread  on  their  surface  are  often  helpful.  The  felt- 
like tissue  called  spongio-piline  steeped  in  hot  water  makes  an 
excellent  fomentation,  but  simple  flannel,  folded  several  times > 
does  very  well.  I  have  used  a  mixture  containing  Liq. 
Morph.  Hydrochlor.  Tl\ii  and  Tinct,  Belladonnse  n\ii  with 
advantage  in  both  conditions,  repeating  the  dose  every  two 
hours  until  sleep  was  induced.  On  one  occasion  I  produced 
marked  poisoning  with  belladonna  in  a  case  of  hsemorrhagic 
infarction  of  the  lung,  after  six  doses  of  this  mixture,  but 
the  occurrence  fortunately  had  no  bad  influence  on  the 
patient's  progress. 

Ew,pyema  may  follow  on  either  a  simple  pleurisy  or  a 
hajmorrhagic  infarction,  and  must  be  dealt  with  surgically. 

Peripheral  iieuritis  is  best  treated  during  the  acute  stage 
b}^  rest  and  a  simple  alkaline  mixture,  such  as  Liq.  Ammon. 
Acet.  3ij  Potass.  Acet.  grs.  10  and  Potass.  Citrate  grs.  101 
After  the  acute  stage  has  passed  off,  mild  Galvanism  and 
massage  are  usually  effective. 

Typhoid  spine  must  be  treated  according  to  the  severity 
of  the  symptoms  and  according  to  its  cause. 

If  a  definite  perispondylitis  is  present,  absolute  rest  is 
essential,  and  the  immobility  of  the  patient  should  be  secured 
by  making  him  lie  between  sandbags  or  on  a  plaster  of  paris 
bed.  Pain  may  be  further  relieved  by  opiates.  It  may  be 
necessary  for  him  to  wear  a  supporting  jacket  for  some  weeks 
after  he  is  allowed  up. 

If  the  condition  is  secondary  to  a  neurasthenic  state,  the 
patient  must  be  treated  on  general  lines,  and  rest,  massage  and 
careful  dieting  will  do  much  towards  a  cure.  Opium  should 
on  no  account  be  used,  but  counter-irritation  by  mustard- 
leaves,  blisters,  or  the  actual  cautery,  will  usually  reduce  the 
pain. 


Enteric   Fecer.  41 

Post-enteric  neurasthenia  is  often  very  troublesome.  The 
patient  should  be  taken  away  from  work,  but,  havinf^  recently 
undergone  a  long  period  of  rest  in  bed  during  his  attack  of 
fever,  it  is  difficult  to  persuade  him  to  rest  properly.  In  spite 
of  the  fact  that  he  has  so  recently  spent  many  weeks  in  bed,  it 
is  best  at  first  to  send  him  back  to  bed  for  a  week  or  two,  feed 
him  carefully  and  well,  and  have  him  massaged.  But  it  is 
necessary  to  be  careful  that  the  masseur  is  not  too  energetic  in 
his  manipulation  of  the  legs,  as  rough  treatment  may  induce 
a  lymphangitis  or  a  phlebitis  with  consequent  thrombosis,  and 
thus  delay  cure.  After  a  preliminary  rest  of  this  kind  it  is 
wise  to  insist  on  the  patient's  going  away  from  his  usual  sur- 
roundings for  a  time,  to  some  pleasant  sea-side  resort  either 
at  home  or  abroad,  where  he  may  have  a  climate  which  per- 
mits him  to  be  much  in  the  open  air  at  any  season  of  the  year. 
He  should  not  be  sent  away  alone,  but  should  be  accompanied 
by  some  congenial  and  cheerful  companion  who  is  willing  to 
give  liim  a  great  deal  of  attention,  and  see  that  he  takes  exer- 
cise well  within  the  limits  of  fatigue.  For  people  who  like 
Iho  sea,  a  voyage  in  sunny  latitudes  is  often  very  beneficial, 
but  it  is  unwise  to  send  a  patient  to  sea  if  there  is  any  marked 
5nelancholia,  as  the  opportunities  for  suicide  on  ship-board  are 
greater  than  on  land. 

If  restlessness  or  any  "phobia"  be  present,  a  mixture  con- 
taining Sod.  Bromid.  grs.  10,  and  Tinct.  Belladonnse  Tl|5, 
is  often  of  assistance,  and  in  sleepless  cases  it  is  wiser  to  be 
content  with  what  sedative  action  can  be  obtained  from  the 
bromides  combined  with  suggestion,  than  to  use  any  more 
powerful  hypnotic  drug,  since  the  drug-habit  is  easily  formed 
in  these  cases.  ISTo  alcohol  should  be  permitted,  for  similar 
reasons. 

Vaccines  have  been  used  recently  in  the  treatment  of 
enteric  fever,  but  as  yet  this  practice  has  not  become  at  all 
general.  The  results  are,  however,  sufficiently  interesting  to 
encourage  a  thorough  trial  of  this  form  of  treatment,  at  least 
in  Hospital.  As  a  remedy  for  the  "typhoid-carrier"  or  for 
any  long-continued  inflammatory  process  due  to  the  B. 
typhosus  which  persists  after  the  fever  has  terminated, 
vaccine-treatment  offers  many  possibilities. 


42  Chapter  II. 

Anti-typhoid  serum  has  been  prepared  by  Chantemesse, 
and  according  to  liis  results  lias  made  some  difference  in  the 
course  and  mortality  of  the  disease,  but  as  the  serum  is  not  in 
circulation  in  this  country  it  is  useless  to  us.  Other  serums 
have  been  prepared,  but  have  not  given  very  encouraging 
results.  The  early  invasion  of  the  blood-stream  in 
enteric  fever  may  account  for  this,  the  serums  prepared  being 
mainly  anti-toxic  and  only  slightly  bactericidal,  while  the 
mixed  character  of  the  infection  may  also  account  for  the  lack 
of  success  of  this  form  of  treatment. 

Epidemiology. — Enteric  fever  may  be  said  to  be  en- 
demic in  the  British  Isles  saving  in  some  rural 
and  sparsely  populated  districts.  But  it  is  subject, 
especially  in  large  urban  centres,  to  definite  and 
periodic  epidemic  variations.  The  spring  and  autumn 
are  the  periods  of  its  maximum  incidence,  the  autumn  shewing 
by  far  the  greater  rise.  Localised  epidemics  have  occurred  in 
connection  Avith  the  supply  and  distribution  of  milk,  while 
water-borne  epidemics  have  been  observed  even  recently  in 
this  country.  Second  attacks  are  not  very  common,  but  do 
occur,  not  usually  within  two  years  of  the  first  attack. 

Method  of  Infection. — Ground  saturated  with  the  excreta 
of  infected  persons  may  retain  its  infectivity  for  long  periods 
and  may,  in  the  form  of  dust,  spread  the  infection  throughout  a 
whole  neighbourhood.  It  is  to  be  remembered  that  both  the 
xirine  and  dejecta  of  typhoid  patients  are  highly  infective,  and 
contact  with  either  of  them,  direct  or  indirect,  must  be 
guarded  against.  It  is  often  very  difficult  to  avoid  infection 
from  the  small  liquid  stools' which  are  frequently  passed  and 
are  apt  to  soil  the  bedclothes  to  such  a  slight  degree  as  to  be 
almost  unobserved,  but  which,  when  dried,  are  capable  of 
spreading  the  infection  eve  a  beyond  the  immediate  attendants. 

Period  of  Infectivity.  —  The  period  of  infectivity 
of    a     case    of     enteric     fever     is     variable.  Usually     it 

has       terminated      by      the      time       a      patient      is       able 
to     go     about     again,     but     it     is     possible     that     many 


Enteric   Fever.  43 

persons  may  be  infective  for  longer  periods,  either  for  a  short 
time  through  the  urine,  or  for  longer  periods  through  the  in- 
testinal canal.  Cases  have  been  known  where  a  chronic  in- 
flammation of  gall-bladder,  quite  without  symptoms,  or  a  mild 
chronic  intestinal  catarrh,  or  a  slight  cystitis  have  been  found 
to  be  due  to  the  B.  typhosus  and  have  been  the  means  of  ren- 
dering a  person  infectious  for  months  or  even  years  after  the 
termination  of  the  original  attack.  "Typhoid-carriers,"  as 
such  persons  are  called,  are  obviously  a  danger  to  the  com- 
munity, and,  from  iheir  difficulty  of  recognition,  are  often  the 
means  of  infecting  very  many  people  with  whom  they  have 
been  in  contact.  Such  a  person  may  be  in  the  service  of  a 
"dairyman  or  farmer  and  may  be  the  mysterious  cause  of  his 
milk  being  the  origin  of  an  epidemic  which,  may  attain  wide 
proportions.  The  recognition  of  a  "typhoid-carrier"  is  often 
difficult.  The  only  certain  method  is  by  the  isolation  of  the 
B.  typhosus  fi'om  the  stools,  the  gall-bladder  being  the  most 
frequent  seat  of  a  concealed  infection,  or  from  the  urine. 
Repeated  examinations  must  be  made  before  a  negative  finding 
can  be  of  any  value,  as  the  presence  of  the  organism  in  the 
stools  or  urine  seems  to  be  variable  and  may  be  only  occa- 
sional. Widal's  test  is  a  very  uncertain  method  of  recog- 
nising a  typhoid-carrier,  since  the  agglutinating  power  of  the 
serum  in  such  cases  is  very  capricious,  and  may  be  absent  for 
months  at  a  time. 

The  history  of  persons  who  are  suspected  of  being  typhoid 
carriers  should  be  carefuUjr  worked  out,  to  discover  if  they 
haA^e  had  any  illness  that  may  have  been  enteric  fever,  but  it 
must  be  remembered  that  certain  people  are  capable  of  har- 
bouring virulent  typhoid  organisms,  although  they  them- 
selves are  not  suffering,  and  never  have  suffered,  from  an 
attack  of  enteric  fever. 

Death  Rate.— The  death-rate  of  enteric  fever  varies 
very  much  in  different  epidemics,  tending  to  be  higher 
at  the  beginning  and  lower  as  the  curve  of  the 
epidemic  increases.  It  is  greater  among  the  poorer 
classes  of  the  community,  partly  from  the  state 
of      their      nutrition      and      their      alcoholic      habits,      and 


44  Chapter  II. 

partly  from  the  fact  that  the  labouring  and  artisan  class 
struggle  on  till  the  last  moment,  and  even  when  laid  up  at 
home,  rarely  remain  completely  at  rest  during  the  early  stages 
of  the  disease,  and  are  extremely  uncontrolled  in  the  matter  of 
diet.  So  that  a  death-rate  of  26  per  cent,  has  been  noted 
within  recent  years  in  the  fever  hospital  of  a  large  urban  dis- 
trict during  an  autumn  epidemic  rise.  In  private  practice 
among  better-class  patients  the  death-rate  is  much  low^er,  and 
taking  it  all  round,  froim  7  to  18  per  cent,  may  be 
said  to  be  a  fair  average,  though  the  death-rate  varies  greatly 
from  year  to  year. 

Home  Prophylaxis.  —  A  patient  suffering  fronv 
enteric  fever  can  be  treated  at  home  only  when  the 
house  is  capable  of  complete  isolation  from  other 
houses.  In     certain     flats     in     the     poorer     districts     of 

town  or  country  there  is  no  separate  W.C.  accommodation 
for  each  family,  but  three  or  four  families  may  share  a  com- 
mon latrine.  Under  these  circumstances  it  is  impossible  to 
permit  an  enteric  patient  to  remain  in  his  own  house,  and  he 
must  be  removed  to  Hospital,  if  necessary  on  a  warrant.  The 
same  rule  applies  when  the  patient  is  staying  in  an  hotel. 
Where  each  family  is  provided  with  a  separate  W.C.  it  is 
necessary  to  insist  on  removal  to  Hospital  only  where  it  is 
impossible  for  the  patient  to  occupy  a  room  which  is  reserved 
solel}'  for  his  own  use.  But  it  is  advisable  to  remove  all 
patients  to  Hospital  who  live  in  flats,  or  who  inhabit  houses 
where  the  dejecta  are  disposed  of  by  means  of  earth  closets, 
and  in  most  cases  it  is  well,  not  only  for  the  patient,  but  for 
the  other  inmates  of  the  household,  to  remove  him  to  Hos- 
pital when  the  accommodation  of  the  house  does  not  permit  of 
a  AV.C.  being  reserved  solely  for  the  disposal  of  the  dejecta  of 
the  patient  and  his  immediate  attendants. 

Isolation  of  the  patient  must  be  strict,  as,  although 
enteric  fever  is  not  so  easily  infectious  as  measles  or  scarlet 
fever,  the  drying  of  the  dejecta  or  urine  on  the  bed-clothes 
makes  the  dissemination  of  the  B.  typhosus  throughout  the 
sick-room  an  easy  matter.  The  sick-room  should  be  arranged 
as  for  any  other  infectious  fever,  and  all  the  usual  precautions 


Enteric   Fever.  45 

must  be  observed.  Special  care  must  be  taken  in  tlie 
t^isinfection  of  the  motions  and  the  urine.  ^^^^J  should  be 
mixed  at  once  with  equal  parts  oi  a  crude  carbolic  liquid,  and 
allowed  to  stand  for  an  hour  or  at  least  half-an-hour  before 
beinj^  permitted  to  pass  into  the  drains. 

Public  Health  Administration.  —  This  resolves  itself, 
as  in  the  case  of  all  infectious  fevers,  into  the 
strict  isolation  of  the  sufferers,  that  they  may  be  as 
little  as  possible  a  source  of  danger  to  the  community.  Care- 
ful enquiry  must  be  made  into  the  history  of  the  illness,  and  all 
those  who  liaA'e  been  in  close  contact  with  the  sick  person  be- 
fore and  during  the  period  of  incubation  must  be  seen,  as  it  is 
in  this  way  that  ambulatory  or  mild,  unrecognised  cases  and 
"typhoid-carriers"  are  sometimes  discovered.  The  milk  and 
food  supply  of  the  household  must  be  noted  and  investigated, 
as  one  or  two  cases  having  the  same  milk  supply  occurring  in 
a  district  throws  suspicion  on  the  dairy  or  the  milk-shop. 

A  frequent  cause  of  a  milk-epidemic  is  that  one  of  the 
assistants  in  a  dairy-farm  or  milk-shop  may  be  suffering  from 
an  unrecognised  attack  of  enteric  fever,  or  may  be  in  close 
attendance,  when  not  at  work,  on  a  relative  who  is  suffering 
from  a  disease  which  turns  out  to  be  enteric  fever,  although  this 
diagnosis  may  not  have  been  made  until  the  occurrence  of  other 
cases.  The  drainage  of  the  patient's  house  and  the 
hygienic  conditions  obtaining  at  his  place  of  work  must  be  in- 
vestigated and  necessary  alterations  made.  The  bed-clothes 
and  mattresses,  and  everything  portable  which  has  been  in 
contact  with  the  patient  and  his  attendants  must  be  disin- 
fected after  the  convalescence  of  the  patient,  and  the  sick- 
room should  be  washed  over  with  formalin  and  re-papered. 
Cotton  and  linen  stuffs  and  blankets  should  be  boiled,  mat- 
tresses treated  by  steam,  and  furniture,  if  stuffed,  subjected 
to  a  formalin-spray,  while  it  may  be  sufficient  in  the  case  of 
books  and  papers  to  use  vapour  of  formalin,  taking  care  that 
they  are  so  placed  that  the  vapour  can  reach  every  part. 

The  improvement  of  sewage-disposal,  the  opening  up  of 
congested  districts,  the  paving  of  back-courts  with  imper- 
meable material,  the  inspection  of  W.C.'s  to  see  that  they  are 


46  Chapter  II. 

kept  clean  and  in  good  order,  the  insistence  on  public  cleanli- 
ness on  the  part  of  everybody  and  the  constant  urging  on 
them  of  personal  cleanliness,  are  all  points  to  which  the 
Health  Autliority  of  a  district  must  pay  attention  if  their 
work  is  to  have  any  good  result  in  lessening  the  incidence  of 
enteric  fever. 


t^"''    '  '"■■'■■:',. 


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(  47   ) 


Chapter   III, 


DIPHTHERIA. 

Synonyms. —  Membranous  Croup. 
Fr.  :      Diphtherie, 
Ger.  :      Diphtheric. 

Definition.  —  An  acute  infectious  fever  characterised 
by  a  local  lesion  of  the  fauces,  tonsils,  and  the  air-passages 
generally,  associated  with  a  prolonged  and  severe  toxaemia, 
with  frequent  paralytic  manifestations.  The  disease  is  due  to 
an  invasion  of  the  fauces  and  air  passages  by  the  Bacillus 
Diphtherise,  discovered  by  Klebs  in  1883. 

Incubation  Period.  —  The  incubation  period  is  usually 
described  as  from  one  to  seven  days,  but  it  is  ex- 
tremely difficult  to  fix  the  maximum.  I  have  known  of  a  child 
who  having  been  exposed  to  infection  was  observed  for  a  fort- 
night after  the  B ,  diph  theriae  was  isolated  from  his  throat,  and 
during  the  fortnight  he  remained  quite  well.  After  that  time, 
however,  he  developed  a  typical  attack  of  diphtheria  under 
the  eyes  of  his  father,  who  was  a  medical  man,  and  whose  zeal 
for  observing  the  behaviour  of  the  bacillus  outran  the  dis- 
cretion which  he  should  have  displayed  for  his  child's  sake. 

Rash.  —  No  rash  has  been  observed  as  typical  of  the 
disease. 

Period  of  Invasion.  —  This  is  usually  very  short, 
amounting  only  to  a  few  hours.  The  patient  feels  slightly 
chilly,  depressed  and  languid,  may  suffer  from  some  headache 
and  nausea  and  is  almost  at  once  conscious  of  sore-throat.  The 
depression  is  often  severe,    and    the    patient    may    be    quite 


48  Chapter  III. 

13rostrated  within  an  hour  of  the  iirst  feeling  of  malaise.  The 
pulse  is  frequently  rapid  out  of  all  proportion  to  the  tem- 
perature, but  may  be  slow,  and  tends  to  be  very  soft.  The 
face  is  rarely  much  flushed,  and  the  fever  is  usually  moderate, 
100°-102o  F. 

Clinical  Types.  —  From  tlie  beginning  of  the  appear- 
ance of  symptoms  the  local  lesion  is  apparent  either 
in  the  nose,  fauces  or  larynx,  and  according  as  one 
or  other  of  these  parts  is  the  primary  seat  of  the 
local  lesion,  the  attack  of  diphtheria  is  called  "nasal," 
^'faucial"  or  "laryngeal."  The  faucial  type  is  by 
far  the  most  common.  The  local  lesion  is  characterised  by  the 
formation  of  a  "false  membrane"  on  the  parts  affected.  This 
"  false  membrane  "  is  produced  by  the  degeneration,  necrosis 
and  desquamation  of  the  epithelial  layer  of  the  mucus  mem- 
brane with  exudation  of  fibrin,  the  result  of  the  local 
action  of  the  toxins  of  the  B.  diphtherias.  Microscopically 
it  is  seen  to  consist  of  a  net-work  of  fibrin  with  some  red 
blood  cells  and  leukocytes  entangled  in  it,  with  much  epithe- 
lial cUhris  and  numerous  clumps  of  bacteria,  the  B.  diph- 
therise,  non-pathogenic  bacteria  of  the  mouth  and,  fre- 
quently, the  staphylococcus  albus  or  aureus  and 
masses  of  streptococci.  In  striking  contrast  to  enteric 
lever,  the  invasion  of  the  blood-stream  by  the  bacillus  diph- 
therise  is  not  at  all  common,  and  while  occasionally  the 
bacillus  has  been  found  in  the  spleen  and  kidney,  the  wide- 
spread lesions  met  Avith  in  diphtheria  are  due  to  the  action 
of  toxins  circulating  in  the  blood-stream  and  manufactured 
by  bacilli  which  occupy  a  superficial  situation. 

Faucial  Diphtheria. — The  usual  site  for  the  membrane  is 
on  one  or  both  tonsils,  the  uvula,  the  posterior  pillar  of  the 
fauces,  the  soft  palate  or,  rarely,  on  the  posterior  pharyngeal 
wall.  On  examining  the  throat,  the  fauces  are  found  to  be 
congested  and  reddened  and  in  the  neighbourhood  of  the  mem- 
brane especially  the  parts  are  swelled  and  angry-looking.  If 
the  membrane  be  situated  on  the  tonsil,  the  tonsil  is  dis- 
tinctly enlarged,  and  tender  to  pressure  from  outside.  The 
appearance  of  the  membrane  on  the  first  day  of  illness  varies 


Diyhthevia.  49 

very  much  in  diil'erent  individuals.  In  some  it  may  appear 
only  as  a  faint  whitish  semi-transparent  film  on  the  inflamed 
mucous  membrane,  in  others  it  appears  as  a  thick  white 
opaque  firm-looking  growth,  like  the  outer  skin  of  a  mush- 
room. As  days  go  on  it  grows  yellower  and  thicker,  while 
the  central  portions  of  the  growth  become  dark  and  the  peri- 
pheral parts  tend  to  curl  up  like  carelessly  dried  wash-leather. 
If  left  unchecked  the  membrane  may  spread  all  over  both  ton- 
sils, the  uvula,  the  pillars  of  the  fauces,  the  soft  palate  and 
posterior  pharyngeal  wall,  extending  upwards  into  the  naso- 
pharynx and  downwards  into  the  larynx  and  bronchi.  Such 
wide  spreading  of  the  membrane  is  seldom  seen  at  the 
present  time,  unless  the  child  has  been  kept  at  home  without 
seeing  a  physician  for  many  days  after  the  onset  of  symptoms. 
The  membrane  may  appear  at  first  as  only  one  patch  which 
spreads,  or  it  may  show  itself  as  numerous  small  dots  of  yel- 
lowish grey,  not  unlike  the  exudate  in  follicular  tonsilitis, 
Avliich  afterwards  coalesce  to  form  a  plaque.  If  any  exudate 
resembling  the  above  descriptions  be  present  on  a  tonsil  it  is 
wise  to  strip  a  little  of  it  off  for  purposes  of  diagnosis.  If  the 
surface  from  which  it  has  been  stripped  is  raw  and  bleeds,  the 
presumption  is  that  the  condition  is  diphtheritic. 

The  general  appearance  of  the  patient  is  not  like  one 
suffering  from  an  acute  fever.  There  is  seldom  any  flushing 
of  the  face,  which  is  usually  pale  and  presents  an  expression 
of  exhaustion  and  languor.  The  lips  may  be  a  little  livid, 
apart  from  any  laryngeal  obstruction,  and  in  profoundly  toxic 
cases,  the  pupils  are  much  contracted.  The  whole  appearance 
and  attitude  of  the  patient  is  one  of  extreme  exhaustion  and 
relaxation,  and  it  is  always  a  surprise  to  the  student,  on 
seeing  his  first  case  of  severe  diphtheria,  to  realise  that  the 
pallid  cachectic  patient  before  him  may  have  been  in  appar- 
ently good  health  less  than  twenty-four  hours  before.  The 
temperature  is  very  moderate,  except  wlien  the  local  lesion  is 
complicated  by  much  pyogenic  infection,  but  the  pulse  is 
usually  rapid  and  weak. 

Sometimes  the  temperature  may  not  rise  above  100°  F.  I 
have  seen  this  in  rapidly  fatal  cases,  and  it  is  well  to  realise 
that  the  gravity  of  an  attack  of  diphtheria  cannot  be  measured 

E 


60  Cliaijter  111. 

in  the  least  degree  by  the  height  of  the  fever.  There  is  very 
frequently  enlargement  of  lymphatic  glands  in  the  neck,  and 
pressure  over  these  glands  usually  produces  some  pain. 

The  progress  of  the  case  now-a-days  depends  very  much  on 
how  long  the  disease  has  lasted  before  its  recognition  by  a 
physician,  because  it  is  now,  or  should  be,  the  ordinary  prac- 
tice, immediately  after  recognising  a  case  as  diphtheria,  to 
give  an  adequate  dose  of  antitoxin,  and  in  some  12-24  hours 
after  giving  the  antitoxin  the  condition  of  the  patient  shows 
a  marked  change  for  the  better  if  treatment  has  been  begun 
within  the  first  forty-eight  hours  after  the  appearance  of  symp- 
toms. The  patient  grows  more  alert  in  appearance,  the  pallor 
lessens,  the  pulse  slows  somewhat  and  the  temperature  begins 
to  fall,  while  the  appearance  of  the  membrane  undergoes  a 
change.  It  becomes  more  translucent  and  less  solid  in  ap- 
pearance, and  there  is  a  distinct  diminution  in  the  surrounding 
inflammation.  Pain  is  lessened  and  the  tenderness  over  the 
cervical  glands  diminishes.  Within  three  or  four  days  the 
membrane  disappears  and  the  patient  begins  slowly  to 
recover  strength,  although  in  many  instances  it  may  be  weeks 
before  he  ceases  to  suffer  from  a  feeling  of  great  prostration, 
and  he  may  continue  to  be  easily  tired  for  months.  In  children 
it  is  noticeable  that  even  after  a  mild  attack  of  short  duration 
their  convalescence  is  slow,  they  may  remain  pallid  and  list- 
less for  weeks,  and  exhibit  a  feebleness  in  walking  out  of  all 
proportion  to  the  apparent  severity  of  the  attack,  even 
though  there  have  been  no  paralytic  manifestations.  The 
membrane  may  separate  in  a  mass  and  be  coughed  up  in 
fairly  large  pieces,  but  it  is  more  common,  where  due  atten- 
tion is  paid  to  the  care  of  the  mouth,  to  find  that  it  gradually 
fades,  becoming  less  thick  and  opaque  until  it  appears  as  a 
slight  semi-transparent  film  on  the  surface  of  the  mucous 
membrane  similar  to  its  appearance  at  a  very  early  stage  in 
the  disease.  It  is  sometimes  difficult  to  say  exactly  on  what 
day  the  membrane  disappears  when  it  fades  in  this  way  and 
does  not  separate  en  bloc. 

When,  however,  several  days  have  elapsed  between  the 
onset  of  the  illness  and  the  giving  of  antitoxin  in  adequate 
doses,  the  course  of  the  disease  is  not  so  mild  and  uneventful. 


Diphtheria. 


51 


even  when  the  type  is  simply  faucial.     It  is  not  uncommon 
among-  the  poorer  and  more  ignorant  classes  o£  the  community 
to  find  that  the  initial  sore  throat  is    disregarded    by    the 
parents  and  it  is  only  when  after  four  or  five  days'  illness  the 
child's  condition  becomes  alarming  that  the  physician  is  called 
in.     Under  these  circumstances  we  have  to  deal  with  a  con- 
dition not  much  less  alarming  than  diphtheria  used  to  be  in 
the  pre-  antitoxin   days,  since  much  of  the  toxin  has  become 
fixed  by  the  tissue-cells  and  is  beyond  the  reach  of  any  anti- 
toxic serum.     It  is  still  no  uncommon  thing  to  find  such  a 
patient  in  a  state  of  the  gravest  asthenia,  with  a  membrane 
spread  widely  over  the  fauces  and  tonsils,  presenting  an  ugly 
greyish  appearance  with  dark  central  areas  and  associated  with 
a  great  deal  of  oral  sepsis,  foul  tongue  and  sordes  on  the  lips 
and  teeth.       The  pulse  is  rapid,  extremely  soft,   and  often 
irregular ;  the  urinary  output  may  be  low ;  the  child  may  have 
a  tendency  to  vomit ;  the  pupils  are  contracted ;  and  the  whole 
aspect  of  the  patient  indicates  an  extremely  grave  toxaemia. 
Even  though  antitoxin,  in  full  doses,  may  be  given  at  once  or 
within  a  few  hours,  the  progress  of  the  case  may  be  quite 
unsatisfactory.     Despite  all  efforts,  the  membrane,  while  per- 
haps   showing    no    sign    of    further    spreading,    may    persist 
for  many  days  and  the  child  may  die  of  toxaemia  within  a 
week. 

It  is  in  this  class  of  case  that  slow  cardiac  failure  occurs. 
The  heart  grows  gradually  weaker,  the  extremities  tend  to  be- 
come cold,  the  capacity  for  taking  even  the  lightest  form  of 
food  grows  less  and  vomiting  may  be  frequent.  Death  may  en- 
sue suddenly  as  the  result  of  cardiac  failure  due  to  the  strain 
of  vomiting,  or  the  heart  may  grow  gradually  more  feeble. and 
rapid  until  death  occurs  from  asthenia.  Some  cases  may 
linger  in  this  toxaemic  condition  for  a  fortnight  or  more  and 
may  display  paralytic  manifestations  either  of  the  heart  or  of 
other  muscles,  or  may  develop  a  low  form  of  broncho-pneu- 
monia and  ultimately  die.  If  recovery  does  take  place,  it  is 
only  after  a  long  and  tedious  convalescence. 

Nasal  diphtheria. — This  has  always  been  recognised  as 
a  particularly  dangerous  type  of  the  disease  and  it  is  easy  to 
understand  why  it  should  tend  to  be  more  serious  and  more 


XJ      *J 


52  Chai)tcr  111. 

fatal  than  the  ordinary  faucial  type.  The  nasal  cavities  are 
inaccessible  and  difficult  to  see  properly,  and  they  are  also 
difficult  to  clean  by  direct  applications.  Thus  a  nasal  diph- 
theria may  proceed  far  without  recognition,  and  concomitant 
pyogenic  infection  is  usual  and  not  easy  to  deal  with.  Unless, 
by  some  fortunate  chance,  membrane  forms  just  within  the 
nostril  and  is  visible  on  superficial  examination,  there  is 
nothing  to  make  a  physician  suspect  that  this  somewhat  severe 
nasal  catarrh  with  rather  profound  constitutional  symptoms  of 
depression  is  due  to  the  B.  diphtheriaj.  It  is  only  when  the 
extreme  prostration  of  the  patient  and  the  sanio-sauguinolent 
nature  of  the  nasal  discharge  makes  it  evident  that  something 
out  of  the  ordinary  is  happening,  that  the  physician  suspects 
a  nasal  diphtheria  and  makes  a  culture  from  the  nose  for  diag- 
nostic purposes,  unless  it  is  known  that  the  patient  has  been 
jDreviously  in  contact  with  a  case  of  diphtheria.  Unless  the 
physician  has  had  some  experience  of  diphtheria,  it  is  fre- 
quently the  case  that  the  discharge  of  a  piece  of  membrane  is 
the  first  sign  which  makes  him  suspicious.  By  this  time,  of 
course,  the  disease  has  been  in  progress  for  many  days  and 
the  toxaemia  is  profound.  Beyond  this  difficulty  in  recog- 
nising the  condition  early,  I  do  not  see  that  a  nasal  infection 
is  worse  than  a  faucial  one,  but  from  what  has  been  said 
before  it  will  be  seen  that  every  day  lost  in  making  a  diag- 
nosis and  beginning  antitoxin  treatment  means  greatly  in- 
creased risk  to  the  patient,  and  it  is  this  delay  in  diagnosis 
that  makes  nasal  cases  appear  to  be  so  malignant. 

Laryngeal  diphtheria. — Similarly,  in  the  case  of  the  laryn- 
geal type  of  the  dit^ease,  on  account  of  the  impossibility  of  view- 
ing the  larynx  by  ordinary  means,  diphtheria  is  naturally  not 
suspected  until  the  exudate  in  the  neighbourhood  of  the  cords  is 
sufficient  to  cause  some  degree  of  stenosis,  and  even  then  time 
may  be  lost  because  a  simple  croup  may  be  diagnosed  in  the 
first  instance,  and  thus  a  dangerous  delay  in  beginning  treat- 
ment is  incurred.  But  besides  this  danger,  which  is  common 
both  to  the  nasal  and  lar^mgeal  types  of  the  disease,  there 
exists  the  danger  of  laryngeal  obstruction  with  all  the  strain 
and  loss  of  aeration  which  follows  and  which  calls  for 
special  treatment.     The  laryngeal  form  may  be  secondary  to 


Diphtheria.  53 

a  primary  faucial  diphtheria  either  by  direct  extension  of  the 
membrane  downwards,  or  to  a  secondary  infection  of  the 
larynx  without  there  being  actual  continuity  between  the 
membrane  on  the  fauces  and  in  the  larynx. 

The  signs  which  are  suggestive  of  laryngeal  diphtlieria 
are  those  of  a  greater  or  less  degree  of  laryngeal  obstruction, 
combined  with  the  usual  toxaemia  of  the  disease,  and  it  is  on 
this  combination  that  the  great  danger  of  this  type  of  the 
disease  depends.  We  shall  see  under  the  section  on  treatment 
how  not  only  the  degree  of  laryngeal  obstruction  but  the  effect 
of  that  obstruction  on  a  poisoned  body  has  to  be  taken  into 
consideration,  so  that  in  some  cases  where  the  laryngeal 
obstruction  may  be  at  the  moment  comparatively  slight  but  the 
toxaemia  severe,  immediate  tracheotomy  is  called  for,  while  in 
other  cases  w^ith  a  great  degree  of  laryngeal  obstruction  the 
toxaemia  may  be  comparatively  slight  and  tracheotomy  may  be 
delayed  wdth  safety.  It  is  a  good  rule  to  be  anxious  about 
those  cases  with  diphtheria  of  the  larynx  who,  while  showing 
signs  of  laryngeal  obstruction,  have  a  pale  face,  a  soft  and 
rapid  pulse,  perhaps  a  little  irregular,  and  contracted  pupils 
and  who  are  quiet  and  feeble-looking.  A  great  degree  of 
cyanosis  in  a  child  even  with  marked  signs  of  laryngeal  ob- 
struction need  not  cause  the  same  anxiety  if  he  seems  capable 
of  effort  and  has  a  strong,  regular  pulse,  albeit  rapid.  The 
amount  of  retraction  of  the  lower  intercostal  spaces, 
the  lower  ribs  and  the  lower  end  of  the  sternum  during  in- 
spiration gives,  in  a  child,  a  fair  indication  of  the  degree  of 
laryngeal  obstruction. 

Another  danger  in  connection  with  larjmgeal  diph- 
theria is  the  tendency  for  broncho-pneumonia  and 
catarrh  of  the  smaller  bronchi  to  occur,  either  due  to 
invasion  by  the  B.  diphtherias  or  to  a  secondary  pyogenic  in- 
fection. Sometimes  the  trachea,  bronchi  and  even  bronchioles 
are  found  post  morteTn  to  be  covered  with  the  typical  "  false 
membrane,"  and  occasionally  a  complete  cast  of  trachea  and 
bronchi  is  coughed  up  during  life  as  the  membrane  separates. 
Such  happenings  are  rarer  now  that  the  use  of  antitoxin  has 
become  more  general.  The  separation  of  a  large  piece  of 
membrane  in  the  trachea  or  larynx  or  the  inhalation  of  a 


54  Chapter  111. 

large  piece  of  membrane  separated  from  the  fauces  may  some- 
times give  rise  to  laryngeal  obstruction,  and  necessitate  im- 
inediate  tracheotomy. 

Aberrant  types  of  Diphtheria. —  The  primary  local  lesion 
ipay  sometimes  be  found  not  in  the  air-passage  or  fauces  but 
on  the  vulva,  the  conjunctivae,  the  lip  or  on  some  wounded 
surface.  In  these  situations  the  general  symptoms  are  usually 
slight,  and  the  disease  is  troublesome  mainly  because  others 
may  acquire  diphtheria  of  the  faucial,  nasal  or  laryngeal 
types  from  such  conditions  while  undiagnosed. 

Differential  Diagnosis. — The  diseases  most  likely  to  be 
confused  with  diphtheria  are  acute  tonsillitis,  scarlatina^ 
-measles,  simple  catarrhal  laryngitis,  and  some  cases  of  croup. 
In  acute  tonsillitis  the  pain  is  much  more  severe  than  is 
common  in  diphtheria,  where  pain  is  usually  moderate  and  may 
be  absent.  Acute  tonsillitis,  too,  is  commonly  accompanied 
by  high  temperature,  a  flushed  face,  a  full  bounding  pulse  and 
all  the  common  signs  of  fever.  As  in  diphtheria,  however, 
the  cervical  glands  are  apt  to  be  enlarged,  but  are  usually 
much  more  tender.  The  follicular  exudate  may  simulate  very 
closely  the  diphtheritic  membrane  in  its  early  stage  and  an 
exudate  firmly  adherent  over  a  portion  of  the  surface  of  the 
tonsil  or  posterior  faucial  pillar  or  a  superficial  slough,  may 
also:  present  a  very  suggestive  appearance;  but  exudate  can 
usually  be  easily  removed  by  swabbing  the  throat,  leaving  no 
bleeding  surface  behind,  while  a  superficial  slough  is 
not  so  easily  stripped  oft  as  the  false  membrane,  and  when 
easily  separated,  seldom  leaves  the  raw  bleeding  surface  which 
is  seen  on  stripping  the  membrane  in  the  early  stages  of 
diphtheria. 

But  in  many  cases  the  differential  diagnosis  apart  from 
bacteriological  examination  is  practically  impossible. 

Similarly,  a  case  of  scarlet  fever  in  which  the  rash  has 
been  so  slight  as  to  escape  observation  and  where  desquama- 
tion has  not  yet  begun  may  be  difficult  to  differentiate  without 
a  bacteriological  examination.  The  character  of  the  tongue 
may  help,  as  a  "strawberry  tongue"  is  not  met  with  in  diph- 
theria, but  the  superficial  ulceration  covered  with  exudate 
which  so  commonly  appears  on  the  tonsils  may  closely  simulate 


Diiyluhe.ria.  ■'  66 

the  false  membrane.  It  is  best  in  all  cases  of  doubt  to  have  a 
swab  from  the  throat  examined  by  culture  before  a  diagnosis  is 
arrived  at,  but  where  there  is  a  reasonable  possibility  that  the 
disease  is  diphtheria  it  is  advisable  to  give  antitoxin  on 
suspicion. 

Measles  may  in  the  early  catarrhal  stage  simulate  laryn- 
geal diphtheria  through  the  occurrence  of  a  laryngitis  with 
signs  of  obstruction,  but  the  facies  of  the  patients  are  very  dis- 
similar. In  measles  there  is  usually  a  flushed,  bloated  face 
with  coryza  and  lachrymation,  and  "Eoplik's  spots"  are  a 
help  towards  differentiation. 

For  bacteriological  diagnosis  a  swab  of  the  suspected  part 
must  be  taken  with  sterilised  cotton-wool  and  placed  in  a 
sterile  test-tube  stopped  with  sterile  cotton-wool  for  examina- 
tion by  culture.  In  taking  the  swab,  great  care  must  be  taken 
to  avoid  touching  the  tongue  and  the  teeth.  At  the  same  time  a 
smear  should  be  made  on  a  glass  slide  from  the  suspected  part, 
dried,  and  sent  with  the  swab  for  examination  by  a  com- 
petent authority.  At  the  present  time,  practically  all 
Medical  Officers  of  Health  are  accustomed  to  carrj^  out  such 
examinations,  or  have  a  bacteriologist  connected  with  their 
department  whose  duty  it  is  to  aid  the  practitioner  in  this 
way,  so  that  practitioners  working  even  among  the  poorest 
classes  of  the  community  have  little  reason  to  be  long  in 
doubt  in  these  cases. 

A  test  tube  can  be  roughly  sterilised  by  a  few  minutes 
boiling,  and  cotton  wool  pulled  out  from  the  centre  of  a  roll 
with  hands  that  are  surgically  clean  will  be  sufficiently  sterile 
to  be  used  as  swab  and  stopper,  in  such  districts  where  suit- 
able apparatus  is  not  supplied  gratis  by  the  Local  Authority. 

Where  it  is  impossible  to  have  such  an  examination  done 
in  reasonable  time  by  the  Local  Authority,  a  smear  from  the 
suspected  throat  should  be  taken  on  a  glass  slide  and  stained 
by  Neisser's  method,  which  roughly  differentiates  the  B. 
diphtherise  from  the  pseudo-diphtheria  group  of  organisms 
which  are  found  both  in  health  and  disease  in  the  throat,  nose 
and  conjunctival  sac.  Staining  with  ordinary  methylene  blue 
or  other  aniline  stains  is  not  sufficiently  accurate,  even  for  an 
approximate  diagnosis. 


56  Chapter  III. 

Complications. — The  complications  of  diphtlieria  most, 
commonly  met  with  are  seco7idary  pyogenic  infection 
of  the  throat,  otitis  media,  nephritis,  bronchial  catarrh y 
and      broncho-pneumonia.  The      multiple      neuritis      so 

frequently  met  with  at  all  stages  of  the  illness  can 
hardly  be  called  a  complication  or  a  sequel,  and 
will  be  described  under  the  heading  of  diphtheritic  palsies. 

Secondary  pyogenic  infection  of  the  throat  is  often  a 
troublesome  complication  and  adds  danger  to  an  already  dan- 
gerous condition,  since  the  toxins  elaborated  by  pyogenic  or- 
ganisms are  not  influenced  in  any  way  by  the  antitoxin,  and 
throw  an  extra  burden  on  the  overtaxed  sj'stem.  The 
pyogenic  infection  often  causes  extensive  sloughing  of  the 
tonsils  and  soft  palate  and  may  be  associated  with  acute  otitis 
media  and  inflammation  of  the  cervical  glands,  and,  possibly,' 
suppuration  of  these  glands. 

Otitis  Tnedia  may  occur  apart  from  any  marked  secon- 
dary infection  of  the  throat  and  may  be  due  to  the  B.  diph- 
therise  itself,  although  it  is  usually  associated  with  the  Diplo- 
coccus  of  Fraenkel  or  one  of  the  ordinary  pyogenic  cocci.  It 
is  not  accompanied,  as  a  rule,  by  the  same  amount  of  pain  as 
is  met  with  in  a  similar  condition  arising  in  association  with 
scarlet  fever  or  quinsy,  and  usually  clears  up  without  the 
necessity  for  operation. 

Nephritis  is  not  a  common  complication.  A  slight  al- 
buminuria is  very  frequently  met  with,  but  is  of  a  "toxic'* 
type,  comparable  with  the  ordinary  "febrile  albuminuria," 
and  is  not  associated  with  any  grave  lesion  of  the  kidney.  In 
such  cases  casts  are  seldom  seen  in  the  urinary  sediment. 
Occasionally,  however,  a  profuse  albuminuria  occurs,  with 
numbers  of  casts  and  perhaps  a  little  blood,  and  in  these 
cases  it  is  reasonable  to  suppose  that  either  the  kidney,  as 
does  happen  sometimes,  is  invaded  by  the  B.  diphtherise,  or' 
that  the  toxremia  is  sufficient  to  produce  a  serious  degenera- 
tion of  the  renal  epithelium. 

Slight  broncliial  catarrh  is  quite  common  in  diph- 
theria, but  if  the  case  has  been  brought  under  treatment  early 
it  does  not  as  a  rule  give  much  trouble.     If,  however,  treatment^ 


Diphtheria.  57 

lias  been  instituted  late,  bronchial  catarrh  and  a  low 
tyj)e  of  broncho-pneumonia  are  often  troublesome  and  dan- 
gerous complications,  and  are  particularly  dangerous  in  cases 
where  tracheotomy  has  been  performed.  This  may  be  due  to 
an  infection  by  B.  diplitheriae,  or  to  a  secondary  infection  by 
the  pneumococcus  or  one  of  the  pyogenic  cocci. 

Vomiting  induced  by  taking  food  is  sometimes  a  very 
dangerous  complication,  not  only  because  of  the  inanition 
which  results  from  insufficient  feeding,  but  also  on  account  of 
the  severe  cardiac  strain  induced  by  the  effort.  In  some  cases 
vomiting  follows  on  any  attempt  to  swallow  even  liquids,  and 
so  immediately  does  it  follow  the  act  of  swallowing  that  it  has 
been  thought  that  it  is  due  to  the  irritation  of  food  passing  the 
fauces.  This  idea  is  supported  by  the  fact  that  feeding  by  the 
nasal  tube  may  result  in  a  cessation  of  the  vomiting,  and 
that  when  it  is  discontinued  the  vomiting  returns. 

Sequelae. —  Besides  the  various  paralytic  manifestations, 
the  most  common  sequelae  are  cardiac  weakness  due  probably  to 
fatty  degeneration  of  the  heart  muscle,  some  degree  of  ge?ieral 
muscular  erifeeblement  and  a  marked  cachexia  which  may 
persist  for  months  after  an  attack  of  diphtheria. 

Cardiac  iveakness  is  very  common  after  an  attack  of 
diphtheria  even  of  moderate  severity,  and  produces  consider- 
able breathlessness  on  slight  exertion  and  often  a  marked 
degree  of  palpitation  and  prsecordial  discomfort.  It  is  pos- 
sible that  some  of  the  sudden  deaths  which  have  been  noted 
as  occurring  weeks  after  the  subsidence  of  all  local  signs  may 
have  been  due  to  heart-failure  following  on  an  extensive  fatty 
degeneration  of  the  cardiac  muscle. 

General  muscular  enfeeblement  is,  of  course,  common 
after  all  febrile  conditions,  but  it  is  so  much  greater  and  of 
longer  duration  after  diphtheria  than  after  almost  any  other 
of  the  infectious  fevers  that  it  appears  worthy  of  special  men- 
tion. So  profound  is  the  effect  of  the  toxins  of  diphtheria  that 
a  patient  may  be  muscularly  inert  and  easily  exhausted  for 
many  months  after  the  usual  period  of  convalescence.  The 
pallor  and  anaemia  which  follow  on  diphtheria  are  frequently 


58  Chapter  111. 

obstinate,  especially  in  children  of  8-14  or  thereabouts. 
Younger  children  are  not  usually  affected  to  the  same  degree.  It 
has  been  suggested  that  ihis  cachexia  is  partly  due  to  the  effects 
of  antitoxin,  but  it  is  more  probable  that  we  see  more  of  the 
post-diphtheritic  cachexia  than  in  pre-antitoxin  days  because 
more  serious  cases  survive  now  than  formerly. 

Diphtheritic  palsies.  —  Palsies  of  various  groups 
of  muscles  are  common  in  all  stages  of  the  disease 
after  the  first  few  days,  and  are  due  to  a  peri- 
pheral neuritis  caused  by  the  action  of  the  diphtheritic 
toxins.  The  most  common  form  is  paralysis  of  the  palate, 
usually  unilateral  on  the  same  side  as  the  local  lesion.  The 
paralysis  is  of  very  varying  degree,  from  a  slight  drooping 
and  immobility  of  one  side,  without  any  alteration  in  voice  or 
difficulty  in  swallowing,  to  a  complete  paralysis  of  the  whole 
soft  palate  with  nasal  speech  and  regurgitation  of  food  into 
the  nose  on  attempting  to  swallow,  A  palatal  palsy  may 
occur  as  early  as  the  first  week  of  the  disease,  especially  if  the 
local  lesion  is  extensive  and  several  days  have  passed  before 
the  commencement  of  treatment,  but  it  may  appear  at  any 
time  up  to  the  third  or  fourth  week.  If  there  be  much  ten- 
dency to  regurgitation  of  food  into  the  naso-pharynx  it  may 
be  necessary  to  feed  for  some  time  by  the  nasal  tube,  to  avoid 
the  risk  of  an  inhalation-pneumonia. 

Another  early  manifestation  of  diphtheritic  palsy  is  the 
occurrence  of  squint,  particularly  internal  squint,  due  to  palsy 
of  the  external  rectus  muscle.  This  is  very  often  the  first  in- 
dication of  a  paralysis  which  may  in  the  end  affect  profoundly 
many  groups  of  muscles  and  prolong  convalescence  for  many 
months  beyond  the  usual  period. 

Of  the  limb  palsies,  that  of  the  peroneal  group 
is  perhaps  the  most  common,  and  next  to  that,  palsy 
of  the  extensors  of  the  wrist,  but  the  whole  limb  may  be  pro- 
foundly paralysed.  On  rare  occasions  a  palsy,  more  or  less  pro- 
found, of  all  four  limbs  may  occur,  or,  rather  less  rarely,  a 
paraplegia.  In  two  cases  of  hemiplegia  which  I  have  seen  as 
a  result  of  diphtheria,  there  was  at  first,  besides  a  profound 
palsy  of  an  arm  and  leg  on  the  same  side,  a  slight  but  distinct 


Diphtheria.  ■■  59 

loss  of  power  in  the  arm  and  leg  of  the  other  side,  which 
cleared  up  in  a  few  days.  The  multiple  neuritis  of  diphtheria 
is  rarely  associated  with  pain  or  tenderness  in  the  affected 
parts. 

The  prognosis  is  usually  good,  although  in  severe  cases 
months  may  elapse  before  complete  recovery.  In  a  few  cases, 
however,  a  palsy  of  the  diaphragm  has  resulted  in  death,  and 
in  many  instances  a  sudden  cardiac  failure  has  occurred  early 
in  the  disease,  presumably  from  paralysis  of  the  vagus.  Before 
such  sudden  cardiac  failure  the  pulse  has  been  found  to  have 
been  weak  and  irregular,  and  as  sudden  cardiac  failure  has  in 
most  instances  followed  on  injudicious  movement  on  the  part 
of  the  patient,  any  irregularity  of  pulse  in  diphtheria  should 
be  considered  as  a  grave  sign  which  may  be  the  forerunner  of 
serious  accident. 

Diphtheritic  palsies  usually  occur  within  four  weeks  from 
the  onset  of  the  illness,  but  I  have  known  many  cases  where  no 
paralysis  was  observed  until  six  or  even  eight  weeks  had 
elapsed.  There  is  little  doubt  that  the  incidence  of  paralysis 
has  been  greatly  lessened  by  the  introduction  of  the  antitoxin 
treatment  properly  carried  out,  although  in  the  earlier  days  of 
the  treatment  it  was  thought  by  many  that  slight  palsies  were 
even  more  frequent  than  formerly.  This  was  probably  due  to 
the  fact  that  antitoxin  was  given  in  quite  inadequate  doses,  so 
that,  while  the  death-rate  was  lowered,  the  process  of  cure  in 
many  cases  w^as  comparable  with  that  of  the  more  severe  cases 
which  recovered  in  pre-antitoxin  times  and  was  attended  with 
many  of  the  accidents  which  were  then  met  wdth,  so  thatj 
many  more  grave  cases  having  recovered,  the  incidence  of  ac- 
cidents among  all  cases  treated  naturally  appeared  to  be 
greater. 

Treatment.  —  The  main  points  in  the  treatment 
of  diphtheria  are  careful  and  absolute  rest  in  bed 
during  at  least  the  first  three  weeks  of  the  disease,  and  the 
proper  use  of  antitoxin.  Absolute  rest  in  bed  is  most 
essential  until  all  risk  of  cardiac  failure  may  reasonably 
be  supposed  to  be  over,  that  is  until  three  or  four  weeks  have 
passed.     In  the  first  fortnight  the  patient  should  be  allowed 


60  Chapter  111. 

to  do  nothing  for  himself,  and  the  bed  pan  and  the  bed  urinal 
sliould  be  used.  He  must  be  watched,  and,  if  old  enough, 
warned,  lest  any  injudicious  movement  induce  an  attack  of 
heart-failure. 

It  is  unwise  to  allow  a  patient  to  get  up  until  at  least 
three  weeks  have  elapsed,  and  if  the  attack  has  been  at  all 
severe  it  is  best  to  keep  him  in  bed  for  four  weeks.  In  really 
bad  cases,  of  course,  it  may  be  necessary  to  keep  him  in  bed 
much  longer,  especially  if  there  have  been  any  complications 
or  palsy. 

But  it  is  in  the  use  of  anti-diphtheritic  serum  that  the 
chief  treatment  of  diphtheria  lies,  and  to  be  successful  one 
must  not  only  use  the  serum  but  use  it  properly.  The  serum 
now  used  is  standardised  in  "units,"  and  accurate  dosage  is 
thus  rendered  possible.  The  principle  of  dosage  should  be  to 
neutralise  the  circulating  toxins  as  quickly  as  possible,  so  that 
none  may  be  left  over  to  be  fixed  by  the  tissue  cells,  because 
when  once  a  toxin  molecule  is  fixed  by  a  cell  it  cannot  be 
neutralised  by  an  antitpxin  either  injected  or  produced  in  the 
body.  If  Ehrlich's  theory  is  to  be  accepted  even  as  a  working 
hypothesis  this  must  be  apparent,  and,  despite  all  statements 
to  the  contrary  by  older  practitioners,  there  is  no  doubt  that 
the  minimum  dose  of  antitoxin,  even  on  the  first  day  of  the 
disease,  should  be  from  6,000  to  10,000  units,  and  if  two  or 
three  days  have  elapsed  since  the  onset  of  illness,  from  10,000 
to  20,000  units  should  be  injected.  It  is  infinitely  better  to 
give  only  one  dose  than  to  give  repeated  doses  at  intervals  of 
twenty-four  hours,  not  only  because  it  is  not  right  to  allow 
the  toxin  to  have  a  greater  opportunity  of  fixing  itself  than 
is  necessary,  but  because  it  is  not  well  to  subject  the  patient 
to  the  irritation  of  repeated  injections.  The  injection  is 
usually  made  subcutaneously  in  the  flank,  and  this  is  a  con- 
venient situation,  as  it  is  least  subject  to  friction  and  pressure 
while  a  patient  is  in  bed.  This  is  the  objection  to  the  loose 
tissue  between  the  shoulders  as  the  site  for  injection. 

In  cases  which  have  been  ill  for  many  days  before  being 
seen,  the  practice  of  intravenous  injection  has  been  adopted  by 
some  with  apparent  success.       The  usual  method  is  to  plunge 


Dipht/ieria.  61 

the  needle  of  the  syringe  directly  into  a  vein  in  the  bend  of  the 
elbow.  The  process  is  a  difficult  one  in  the  case  of  children 
on  account  of  the  small  size  and  thin  walls  of  the  veins.  1 
know  of  no  untoward  result  following  this  practice  save  in  a 
case  of  my  own,  when  a  boy  died  suddenly  within  ten 
minutes  after  an  intravenous  injection  had  been  given.  The 
cause  of  death  in  this  case  is  unknown,  but  I  confess  that  the 
occurrence  made  me  fight  shy  of  intravenous  injections  from 
that  time. 

One  interesting  point  to  be  remembered  in  connection 
with  serum  treatment  is  that  for  some  time  after  injection  cer- 
tain patients  become  unduly  sensitive  to  horse-serum.  This  is 
important  in  considering  the  advisability  of  giving  a  second 
dose  of  serum  on  the  occurrence  of  a  second  attack  within  a  few 
weeks  or  months  of  a  first,  and  is  also  a  fact  to  be  recorded 
against  the  habit  which  certain  physicians  have  of  giving  more 
serum  on  the  occurrence  of  a  palsy.  In  the  latter  instance 
the  giving  of  serum  is  probably  futile,  as  considerable  fixation 
of  the  toxin  molecules  has  already  taken  place,  and  it  is  un- 
likely that  the  neutralisation  of  the  small  amount  of  free 
toxin  which  possibly  remains  in  circulation  will  have  any 
effect  in  arresting  the  palsy.  If  a  full  dose  of  serum  be  given 
to  a  patient  who  is  hypersensitive,  a  condition  of  anaphylaxis 
is  produced;  that  is  to  say,  certain  alterations  take  place  in 
the  behaviour  of  the  ordinary  phenomena  of  "  serum-disease  " 
which  will  be  discussed  later,  and  profound  constitutional 
disturbances,  collapse  and  even  death  may  ensue. 

This  condition  of  hypersensitiveness  to  horse-serum  may 
tegin  about  a  fortnight  after  a  full  dose  and  continue  for  some 
months  or  even  years,  so  that  it  is  wise  not  to  give  a  second 
full  dose  of  serum  within  these  limits  without  taking  certain 
precautions.  It  is  said  that  danger  from  anaphylaxis  may  be 
avoided  by  the  giving  of  a  very  small  dose  of  50  or  100  units 
of  antitoxin  twelve  hours  before  the  full  dose,  when  a  patient 
has  shown  himself  susceptible  to  serum-disease  within  a  few 
years  previously. 

Serum  disease  is  the  name  given  to  those  constitutional 
and  local  symptoms  which  follow  the  injection  of  antitoxic 
■sera  derived  from  the  horse,  as  in  diphtheria  and  plague.  The 


62  Chapter  III. 

most  common  results  are  the  occurrence  of  an  urticarial  rash 
both  at  the  seat  of  the  puncture  and  on  the  body  generally. 
The  rash  is  often  morbilliform,  often  scarlatiniform,  and,  like 
all  other  so-called  "toxic"  rashes,  has  a  tendency  to  be  most 
marked  about  the  joints.  Whether  morbilliform  or  scarlatini- 
form, it  is  inclined  to  appear  in  blotches  and  is  often  in- 
tolerably itchy.  The  appearance  of  the  rash  is  frequently  as- 
sociated with  headache,  nausea  and  general  malaise,  and  occa- 
sionally with  some  rise  in  temperature,  which,  however,  is 
rarely  very  high  unless,  as  sometimes  happens,  there  is  besides 
the  above-mentioned  symptoms,  some  pain  in  the  joints.  The 
joint-pains  in  serum-disease,  associated  as  they  frequently  are 
with  fairly  high  fever  and  considerable  constitutional  dis- 
turbance, may  closely  simulate  an  attack  of  acute  rheumatic 
fever,  but  they  are  not  commonly  so  severe  and  may  only 
exist  as  a  very  slight  affection  indeed.  They  attack  as  a 
rule  those  joints  on  which  most  strain  falls  in  the  patient's 
occupation,  and  are  accompanied  by  slight  swelling  which  is 
mainly  peri-articular,  but  in  some  cases,  fairly  large  effusion 
into  the  joint  or  neighbouring  synovial  pouches  has  been  ob- 
served. Serum  disease  usually  appears  some  8-14  days  after 
the  injection  of  serum  and  lasts  for  about  a  week  or  less,  but 
in  rare  cases  relapses  occur  and  repeated  outbreaks  of  rash  with 
fever  and  joint-pains  may  be  observed,  separated  by  a  few 
days  of  normal  temperature  and  freedom  from  symptoms. 

When  a  patient  has  been  hypersensitised  by  a  previous  in- 
jection of  serum,  the  phenomena  of  serum  disease  appear 
rapidly,  almost  without  any  incubation-period,  so  that  rash, 
malaise,  headache  and  fever  may  show  themselves  within  a 
few  hours  of  the  injection.  The  constitutional  symptoms  of 
hypersensitised  patients  are  usually  much  more  severe  than  in 
those  who  have  had  no  serum  previously  and  may,  indeed, 
give  cause  for  grave  alarm  from  the  collapse  from  which  the 
patient  suffers.  In  several  instances  death  has  followed  an 
injection  of  serum  when  the  patient  has  been  in  this 
condition  of  anaphylaxis. 

Local  treatment  of  the  throat  and  nasal  passages  must  be 
carried  out  with  some  care,  but  no  attempt  ought  to  be  made 


Diphtheria.  63 

to  remove  the  membrane  or  apply  strong  disinfectants  to  the 
throat,  on  account  of  the  pain  and  discomfort  which  this  en- 
tails on  the  patient.  The  fauces  may  be  sprayed  frequently 
Avith  a  warm  solution  of  Sod.  Bicarb,  or  Sod.  Biborate,  and 
the  mouth  and  fauces  may  be  swabbed  out  several  times  a  day 
with  a  mixture  of  Glycerine  of  Borax  and  warm  water,  but 
strong  carbolic  preparations  or  other  powerful  local  anti- 
septics should  be  avoided,  unless  there  be  a  great  deal  of 
secondary  pyogenic  infection. 

In  a  case  of  laryngeal  diphtheria,  the  possibility  of 
tracheotomy  being  necessary  is  always  present  in  the  mind  of 
the  physician,  and  the  attitude  towards  this  operation  has 
changed  very  greatly  since  the  introduction  of  the  antitoxin 
treatment.  Formerly,  on  account  of  the  tendency  of  the  mem- 
brane to  spread  to  the  cut  surface,  it  was  only  performed  as 
a  last  resort,  and  many  practitioners,  both  in  hospital  and 
private,  had  given  it  up  altogether  on  account  of  the  appalling 
mortality  which  attended  it.  But  now,  when  spreading  of 
the  membrane  is  practically  unknown  after  adequate  doses  of 
antitoxin,  the  operation  holds  out  chances  of  success  which 
rob  it  of  its  terrors,  and  while  its  mortality-rate  is, 
naturally,  rather  high,  it  is  not  such  as  to  make 
a  practitioner  hesitate  in  its  performance.  The  question 
is,  when  should  the  operation  be  performed,  and  when  should 
a  chance  be  given  for  the  swelling  of  the  cords  to  subside  under 
the  influence  of  antitoxin  and  other  treatment? 

It  is  to  be  remembered  that  in  many  cases  the  apparent 
obstruction  is  increased  by  spasm,  and  many  of  the  symptoms 
are  the  result  of  fear  on  the  part  of  the  patient.  Unless  the 
obstruction  is  very  marked,  as  evidenced  by  much  indrawing 
of  the  intercostal  spaces,  and  the  lower  ribs  and  lower  end  of 
the  sternum  in  children,  with  a  great  degree  of  cyanosis  or 
exhaustion  on  the  part  of  the  patient,  or  unless  a  fair  degree 
of  obstruction  is  present  in  association  with  a  very  profound 
toxaemia  indicated  by  a  ''pale  lividity"  of  the  lips  and  face, 
coldness  of  the  skin  generally,  and  contraction  of  the  pupils, 
it  is  wise  to  wait  for  some  hours  after  giving  antitoxin,  in  the 
hope  that  some  amelioration  of  the  symptoms  will  take  place. 


64  Chapter  111. 

In  the  meantime,  a  dose  of  3^-3^'^  °^  whisky,  according  to 
the  age  of  the  child,  in  hot  water  with  sugar,  or  the  hypoder- 
mic injection  of  a  small  quantity  of  morphine,  say  from  i\th 
to  |-th  of  a  grain  according  to  age,  will  help  to  reduce  the 
extra  obstruction  due  to  spasm  and  quiet  the  restlessness  of 
the  patient,  and  the  surrounding  of  the  bed  with  an  impro- 
Tised  tent  into  which  steam  is  led  by  a  funnel  from  a  boiling 
hettle,  will  ensure  the  warm  moist  atmosphere  which  is  neces- 
sary for  those  who  suffer  from  an  acute  laryngeal  inflamma- 
tion. During  this  time  of  waiting  the  physician  should  be  in 
close  attendance  on  the  patient  and  all  should  be  in  readiness 
for  the  performance  of  the  operation,  since  it  is  quite  usual 
tor  a  sudden  spasm  to  occur  which  may  threaten  the  life  of  the 
j)atient  should  the  operation  be  delayed  longer  than  ten  or 
fifteen  minutes.  One  must  remember  that  in  the  laryngeal 
obstruction  of  diphtheria  a  child  is  handicapped  for  the  fight 
by  a  toxsemia  which  has  a  profoundly  depressant  effect  on  the 
lieart,  and  he  cannot,  therefore,  endure  much  struggling.  If, 
after  a  few  hours  of  palliative  treatment,  the  conditions  are 
no  better  but  rather  worse,  the  operation  should  be  performed 
without  further  delay. 

To  those  who  have  had  much  clinical  experience  of  diph- 
theria it  is  comparatively  easy  to  decide  when  the  operation  is 
necessary,  but  to  those  whose  clinical  experience  is  yet  small, 
I  would  say  that  it  is  better  to  be  too  early  than  too  late;  it 
is  better  to  operate  sometimes  needlessly  than  to  have  a 
patient  die  with  laryngeal  obstruction  without  tracheotomy 
Iiaving  been  performed. 

The  instruments  necessary  for  the  operation  are  few.  A 
small  scalpel  with  a  keen  edge,  a  couple  of  artery  forceps  to 
retract  the  edges  of  the  wound,  a  blunt  retractor  to  pull  down 
the  isthmus  of  the  thyroid  should  it  be  in  the  way,  some  pres- 
sure forceps  to  stop  excessive  bleeding  should  a  large  vein  be 
cut,  and  some  sterile  ligatures,  are  all  that  is  necessary.  When 
the  child  is  unconscious  no  ansesthetic  will  be  required  and, 
indeed,  when  there  is  much  cyanosis,  the  sensation  of  the  child 
is  so  blunted  that  the  pain  of  the  operation  is  slight,  and  the 
patient  can  be  easily  controlled.     But  when  the  child  is  strong 


Diphtlieria.  65 

and  struggles  much,  a  small  quantity  of  chloroform  is  neces- 
sary to  keep  it  quiet,  and  the  I'isk  of  accident  is  so  remote  that 
it  is  quite  outweiglied  by  the  additional  comfort  to  the  operator 
and  the  increased  chances  of  rapid  and  successful  operation. 
1  have  never  seen  any  evil  result  from  the  careful  administra- 
tion of  chloroform  in  small  quantity  by  the  "open"  method, 
even  in  profoundly  "toxic"  cases,  but  I  have  seen  a  child's 
heart  fail  after  much  struggling  where  the  operator  feared  the 
anaesthetic.  When  the  practitioner  has  had  much  experi- 
ence of  the  operation  it  is  extraordinary  how  rapidly  it  may  be 
done  even  with  a  struggling  child,  but  when  he  has  had  little 
experience  it  is  wiser  to  be  slow  and  certain  than  to  attempt 
rapidity  and  cut  what  should  not  be  cut  or  lose  the  trachea  for 
a  time.  I  do  not  propose  to  describe  the  operation,  but  I 
would  say  this,  that  much  of  its  success  depends  on  the  in- 
cision through  the  skin  and  subcutaneous  tissue  being  ac- 
curately in  the  middle  line  as,  if  it  has  been  made  a  little  to 
one  side,  the  search  for  the  small  soft  trachea  in  the  fat  neck 
of  a  child  is  often  irritating  and  disconcerting. 

In  an  adult,  tracheotomy  is  rarely  necessary  in  diphtheria, 
and  should  a  sudden  alarming  obstruction  occur,  it  may  be 
rapidly  relieved  by  putting  a  knife  through  the  crico-thyroid 
membrane,  an  operation  which  can  be  done  in  a  moment  and 
involves  no  preparation  or  anaesthesia. 

The  after-treatment  of  a  tracheotomy  is  important.  Care 
must  be  taken  to  keep  the  tube  moist  and  free,  by  covering  the 
opening  with  a  hot  moist  sponge  which  should  be  frequently 
changed  during  the  first  twelve  hours  after  the  operation, 
and  secretion  should  be  encouraged  by  a  hot  alkaline  steam 
sprayed  into  the  opening  of  the  tube  every  few  hours.  The 
inner  tube  should  be  removed  and  cleaned  at  least  twice  in 
the  day,  and  if  loosened  membrane  gives  rise  to  any  obstruc- 
tion it  may  be  removed  by  cleaning  the  outer  tube  with  a 
feather  or  sucking  it  out  with  a  syringe  and  rubber  tube.  It 
may  be  that  the  tracheotomy  tube  will  have  to  be  taken  out, 
and  if  this  is  the  case  the  wound  must  be  held  open  by  a  double 
retractor,  while  the  trachea  is  cleaned.  At  the  end  of  the 
first  day  after  operation  the  inner  tube  should  be  taken  out 


66  Chaftcr  111. 

and  tlie  end  of  the  outer  tube  should  be  covered  and  trial  made 
of  the  patient's  capacity  to  breathe  through  the  larynx.  Simi- 
lar trials  should  be  made  at  intervals  of  twelve  hours,  and  be- 
tween two  and  three  days  after  the  operation  the  tube  may 
be  removed  and  as  a  rule  does  not  need  to  be  returned.  In 
some  cases,  however,  the  patient  may  have  difficulty  in 
breathing  again  and  reintroduction  of  the  tube  may  be  neces- 
sary for  twelve  hours.  Houghly  speaking,  the  shorter  the 
time  the  tube  remains  in  the  larynx  the  better,  as  if  it  has  to 
remain  for  a  long  time  troublesome  granulations  may  appear 
in  the  trachea  and  may  require  special  treatment.  Sometimes 
tlie  introduction  of  a  larger  tube  for  a  day  or  two  is  sufficient 
to  check  these  granulations,  but  occasionally  they  require 
scraping  or  treatment  with  "blue-stone." 

As  a  general  principle,  the  tube  used  should  be  as  large 
as  can  be  introduced  into  the  larynx  without  distress.  The 
wound  should  be  cleaned  twice  daily  with  a  saturated  solution 
of  boric  acid  and  a  piece  of  boric  lint  should  be  placed  under 
the  flange  of  the  tube.  After  the  tube  is  removed,  the  wound 
may  be  covered  with  sterile  gauze,  dusted  with  powdered  boric 
acid  crystals,  and  kept  in  place  by  a  light  gauze  bandage. 
The  wound  usually  heals  in  about  a  week  after  the  tube  is 
removed.  In  a  few  cases  patients  have  been  known  to  acquire 
a  "tube-habit"  and  seem  unable  to  give  it  up  for  many  weeks.  I 
have  tried  to  trick  certain  of  them  by  removing  the  tube  rapidly 
during  sleep  and  have  noticed  that  breathing  was  perfectly 
easy  and  natural  while  they  were  unconscious,  but  when  they 
woke  and  found  the  tube  gone,  an  attack  of  laryngeal  spasm 
came  on.  It  is  a  good  thing  to  make  such  a  patient  wear  a 
corked  tube  for  some  days  before  trying  to  train  them  to  do 
without  it  altogether. 

No  trouble  results,  as  a  rule,  from  the  contraction  of  the 
scar  left  after  the  wound  heals,  but  one  or  two  cases  have  been 
recorded  where  a  cicatricial  stenosis  of  the  larynx  has  oc- 
curred. 

Intubation  has  been  urged  by  many  as  a  substitute  for 
tracheotomy  in  many  cases.  It  is  possible  that  in  skilled 
hands  and  in  hospital  practice  it  may  be  attended  with  small 


Diphtheria.  67 

risk,  but  even  under  these  conditions,  where  the  tube,  if  dis- 
lodged, can  be  quickly  replaced  by  the  physician  in  charge,  in- 
tubation has  frequently  to  be  followed  by  tracheotomy.  In 
private  practice  it  is  not  to  be  recommended.  The  operation 
requires  a  considerable  amount  of  training  and  manipulative 
dexterity,  and  one  cannot  expect  a  nurse  to  replace  a  dis- 
lodged intubation  tube,  so  that  the  proximity  of  the  practi- 
tioner is  necessary  to  a  degree  impossible  for  one  engaged  in  a 
practice  of  any  size.  After  tracheotomy,  on  the  other  hand, 
the  tube,  if  dislodged,  can  be  replaced  by  any  nurse  who  has 
had  an  ordinary  training  in  fevers,  and  the  practitioner  is  able 
to  do  his  work  properly  without  the  danger  of  impossible  calls 
on  his  time.  The  objections  to  intubation  in  this  way  are  very 
practical,  and  the  operation  has  not  taken  hold  in  this  country 
for  these  reasons.  However,  if  a  practitioner  is  able  to  devote 
the  time  necessary  to  one  patient,  intubation  will  be  found, 
in  a  certain  number  of  cases,  to  obviate  the  need  of 
tracheotomy,  when  otherwise  the  major  operation  would  have 
to  be  performed. 

Treatment  of  Complications. — Secondary  pyogenic  infec- 
tion of  the  throat  with  ulceration  must  be  treated  as  in  Scarlet 
Eever.  (q.  v.) 

Otitis  Tnedia  yields  readily,  as  a  rule,  to  swabbing  out 
the  ear  with  some  antiseptic  cotton-wool  and  insufflation  of 
Iboric  acid  powder.  I  have  never  seen  mastoid  abscess  or 
periostitis  following  a  diphtheritic  otitis  media. 

Broncho-pneuTnonia  and  Bronchial  catarrh  must  be 
treated  on  general  lines.  If  there  is  much  embarrassment  of 
breathing,  heat  over  the  chest,  especially  in  young  children, 
will  often  relieve  it,  and  a  mixture  of  Acetate  of  Ammonia 
3ss-3i  with  Ammon,  Carb.  grs.  i-iv  appears  to  help  the 
condition,  the  dosage  to  be  calculated  according  to  the 
child's  age.  I  have  not  seen  belladonna  do  any  good  in  the 
pulmonary  complications  of  diphtheria.  The  question  of 
stimulation  arises  here  as  in  many  other  conditions  associated 
with  the  acute  fevers,  and  I  believe  that,  as  in  whooping  cough 
and  measles,  children  suffering  from  broncho-pneumonia  and 

F    2 


68  diaper  III. 

broncliial  catarrli  benefit  greatly  from  either  doses  of  30 
minims  of  Avliisky  every  3  or  4  hours  throughout  the  day  or  a 
hii'ger  dose  of  "^ii-lyxv  at  night.  The  action  of  the  alcohol 
is,  I  think,  mainly  sedative,  and  it  is  the  safest  hypnotic  to 
give  to  a  child  whose  heart  is  poisoned  with  the  toxins  of 
diphtheria.  Opium  is  distinctly  counter-indicated.  If,  when 
recovery  has  begun,  the  process  of  resolution  is  slow,  the  use 
of  Ammonium  Iodide  in  doses  of  from  2  to  5  grains  three  or 
four  times  in  the  day  will  often  hasten  matters. 

Inflammation  of  tlie  cervical  glands  should  be  dealt  with 
by  careful  treatment  of  any  septic  condition  of  the  throat  or 
mouth,  and  by  the  application  of  dry  cotton-wool  to  the  neck. 
Should  suppuration  occur,  the  abscess  must  be  opened  and 
dressed  with  large  moist  dressings  at  least  once  a  day. 

If  nephritis  occur,  the  patient  must  be  kept  warm,  special 
attention  must  be  paid  to  the  action  of  the  skin  and  bowels, 
large  quantities  of  fluid  should  be  taken,  and  the  use  of  the 
alkaline  diuretics  is  to  be  recommended. 

The  treatment  of  vomiting  is  often  troublesome.  If  it 
follows  on  cardiac  failure,  as  it  frequently  does,  its  treatment 
must  be  mainly  directed  to  the  heart,  but  the  application  of 
hot  fomentations  to  the  epigastrium  and  the  giving  of  small 
doses  of  champagne,  frequently  repeated,  will  sometimes  help 
in  getting  rid  of  this  most  troublesome  complication,  but  in 
association  with  cardiac  failure  it  is  always  an  ominous  sign. 
Where  it  is  due  simply  to  the  passage  of  food  over  the 
fauces,  feeding  with  diluted  or  predigested  milk  by  the  nasal 
tube,  if  necessary  for  many  daj'S,  has  very  frequently  the  effect 
of  stopping  the  vomiting.  Feeding  with  the  nasal  tube  has  the 
advantage  over  rectal  alimentation  in  that  the  child's  nutrition 
suffers  less  and  there  is  no  danger  of  the  occurrence  of  scurvy 
should  the  process  have  to  be  continued  over  a  long  time. 

The  diphtheritic  palsies  are  treated  at  first  by  rest  and 
warmth.  A  severe  palatal  palsy  will  necessitate  nasal  feeding 
until  recovery  is  sufficient  to  allow  of  swallowing  without  re- 
gurgitation of  food  into  the  naso-pharynx.    Paralysis  of  a  liml) 


Diphtheria.  69 

is  best  treated,  as  general  convalescence  is  established,  by  mas- 
sage and  mild  galvanism.  Small  doses  of  strychnine,  hypoder- 
mically  or  by  the  mouth,  are  recommended  for  all  forms  of 
diphtheritic  palsy. 

Epidemiology. ^ — Diphtheria  is  endemic  witliin  the  British 
Islands,  and  is  liable  to  no  very  definite  variations. 

It  may  make  its  appearance  in  epidemic  form  as  the  result 
of  a  school  or  milk  infection,  or  in  connection  with  some 
insanitary  spot  like  an  unclean  pigsty.  It  is  always  a  moot 
point  as  to  whether  defective  drainage  has  anything  to  do 
with  the  occurrence  of  diphtheria  in  a  household,  and  I  think 
that  the  result  of  the  defective  drainage  may  be  looked  upon 
as  a  strong  predisposing  cause,  although  perhaps  not  the  im- 
mediate cause,  of  the  disease,  from  its  tendency  to  produce  in 
the  household  a  lowered  vitality  and  general  ill  health  with 
faucial  inflammations  of  greater  or  less  severity.  It  seems 
likely  that  the  bacillus  may  remain  potentially  active  in 
buildings  and  in  soil  for  long  periods,  as  is  instanced  by 
periodic  outbreaks  of  diphtheria  in  certain  hospital  wards  and 
in  connection  with  the  turning  up  of  ground  in  the  neighbour- 
hood of  dwelling  houses.  In  schools  it  is  easily  conveyed  from 
one  child  to  another  through  the  medium  of  slates,  pencils, 
boots,  games,  and,  among  girls,  of  kissing.  It  is  possible 
that  infected  clothing  may  remain  dangerous  for  a  long  time. 

Period  of  Infeetivity.  —  The  length  of  time  during  which  a 
patient  who  has  suffered  from  diphtheria  may  remain  infec- 
tious is  very  variable.  The  bacillus  has  been  found  to  be 
absent  from  the  throat  as  early  as  the  end  of  the  second  week. 
In  view  of  the  uncertainty  which  attends  the  recovery  of  the 
bacillus  from  the  throat  it  is  well  to  consider  that  all  patients 
are  infectious  for  at  least  six  weeks,  and  no  child  should  be 
allowed  to  return  to  school  until  eight  weeks  have  elapsed  from 
the  beginning  of  treatment. 

The  death  rate  in  diphtheria  varies  greatly  according  to 
the  clinical  type  of  the  disease,  the  age  of  the  patient,  and 
the  day  of  disease  on  which  antitoxin  has  been  given. 


70 


Chapter  III. 


I  append  tables  of  death  rates  from  the  City  of  Glasgow 
Fever  Hospitals  showing  the  effect  of  treatment  and  age  inci- 
dence on  the  mortality-rates. 


Pre-antitoxin  Years  :   1871-1894. 

Antitoxin  Years  : 
1895-1909. 

Ages. 

Cases. 

Deaths. 

Per  cent. 

of 
Mortality 

Cases. 

Deaths: 

Per  cent, 
of 

Mortality 

0-1 

17 

12 

70-6 

177 

73 

41-25 

1-2 

91 

61 

67-0 

475 

145 

30-5 

2-3 

85 

51 

60-0 

522 

120 

22-9 

3-4 

106 

49 

46-2 

491 

70 

14-25 

4-5 

82 

38 

46-3 

424 

58 

13-6 

5-10 

233 

93 

39-9 

1127 

106 

9-4 

10-20 

93 

9 

9.6 

391 

17 

4-3 

20-30 

66 

6 

9 

198 

5 

2-5 

30- 

17 

0 

0 

101 

5 

4-9 

Total 

790 

319 

40-4 

3906 

599 

15-3 

Home  Prophylaxis.  —  Patients  nursed  at  home  must  be 
rigidly  isolated  during  the  infectious  period,  and  the  room 
prepared  in  the  usual  way  as  a  sick  room.  No  patient  may 
remain  at  home  unless  the  house  is  of  sufficient  size  to  provide 
a  room  solely  for  himself  and  his  attendant.  It  is  well  for  the 
practitioner  to  inject  all  those  of  the  household  with  a  protec- 
tive dose  of  antitoxic  serum,  say  300-500  units.  The  discom- 
fort subsequent  on  this  small  dose  is  slight,  as  a  rule,  although, 
if  care  be  not  taken  in  diet  and  regulation  of  the  bowels, 
"serum-disease"  is  fairly  common,  and,  because  of  the  neg- 
lect of  simple  precautions  of  this  kind,  "serum  arthritis" 
occurs  with  greater  frequency  in  persons  who  have  received  a 
protective  injection  than  in  those  who  have  been  injected  for 
purposes  of  cure.  It  is  remarkable  how  the  injection  of  a 
small  amount  of  antitoxic  serum  will  prevent  the  spread  of 
diphtheria  in  a  household  or  in  a  school.     After  the  recovery 


Diphtheria.  71 

of  the  patient  disinfection  must  be  thorough,  and  during  his 
illness  everything  which  comes  in  contact  with  him  must  bo 
steeped  in  disinfectant  and  boiled  before  coming  in  contact 
with  others. 

Public  Health  Administration. —  In  every  case  where  the 
accommodation  at  home  is  not  adequate  for  suitable  isolation, 
the  patient  must  be  removed  to  Hospital.  The  Local  Authority 
should  provide  means  for  the  examination  by  a  com- 
petent person  of  swabs  from  suspected  throats,  and 
should  supply  sterile  swabs  for  the  use  of  the  prac- 
titioner. The  question  of  the  supply  of  antitoxin  gratis 
or  at  a  reduced  price  is  an  important  one,  as  many  people 
cannot  afford  to  bear  the  cost  of  serum-treatment,  even 
though  their  houses  are  quite  suitable  for  the  nursing  of  diph- 
theria. In  some  districts  this  is  done,  but  the  practice  is  not 
yet  general.  Similarly,  the  protective  injection  with  300-500 
units  of  antitoxic  serum  of  all  children  in  a  school  when  one 
or  two  cases  have  occurred  should  be  undertaken.  The  drains 
of  a  house  or  school  where  diphtheria  has  appeared  must  be 
carefully  tested,  and  put  right  if  found  to  be  defective,  and 
schoolrooms  as  well  as  living-rooms  should  be  stripped  of 
paper,  sprayed  with  formalin  solution  and  repapered  or  white- 
washed. The  milk  supply  of  a  household  where  diphtheria 
has  appeared  must  be  carefully  investigated.  All  bedding 
and  clothing  which  has  been  in  contact  with  the  patient  should 
be  steamed,  and  more  perishable  furniture  and  books  treated 
with  formalin  spray  or  vapour. 


(    72    ) 


Chapter  IV. 


THE   PLAGUE. 

Synonyms.— Bubonic  Plague  :     Pestis  Bubonica. 
Fr.  :      La  Peste. 
Ger.  :     Die  Pest :  Bubonpest. 

Definition. —  An  acute  infectious  fever  associated  with 
enlargement  of  glands  from  wliicli,  as  well  as  from  tlie  blood 
stream  and  viscera,  the  causal  organism  may  be  recovered — 
the  B.  Pestis,  discovered,  independently,  in  1894  by  both  Kita- 
sato  and  Yersin. 

Incubation  Period.  —  This  varies  from  a  few  hours  to 
about  a  fortnight,  but  the  usual  period  is  from  three  to  eight 
days. 

Rash.  —  There  is  no  typical  rash  in  plague  as  in  typhus 
or  scarlet  fever,  but  hsemorrhagic  areas  varying  from  small 
pin-head  petechiee  to  blotches  about  half-an-inch  in  diameter 
are  frequently  found  on  the  skin  over  the  body,  especially  on 
the  more  exposed  parts.  During  the  period  of  invasion  and 
early  stage  of  fever  the  skin  is  usually  flushed  and  dusky  and 
may  show  a  peculiar  sub-cuticular  mottling  such  as  is  seen  as 
a  prodromal  eruption  in  typhus  and  measles. 

Period  of  Invasion. — The  symptoms  of  invasion  last  for 
a  very  varying  period  according  to  the  malignity  of  the  at- 
tack. In  certain  cases  there  may  precede  the  stage  of  fever 
a  day  or  two  of  severe  headache,  malaise,  slight  shivering, 
aching  in  the  limbs,  vertigo  and  great  weariness,  with  some- 
times drowsiness  and  sometimes  vigilance  and  evil  dreams, 
and  during  this  time  the  temperature  may  be  normal  or  only 


The  Flarjue.  73 

very  slightly  raised.  In  other  cases  the  disease  is  ushered  in 
by  vomiting,  violent  lieadache,  considerable  shivering,  and 
sometimes  diarrhosa,  with  sudden  and  rapid  rise  of  tempera- 
ture in  a  few  hours  to  highly  febrile  registers,  103*-'  to  106° 
F.  being  frequently  observed.  The  rise  of  temperature  is  not 
commonly  quite  so  sudden  as  in  malaria,  but  is  more  compar- 
able with  typhus. 

Stage  of  Fever. —  -The  pulse  and  respiration  are  greatly 
increased  in  rate. 

The  face,  in  white-skinned  persons,  is  of  a  dusky  pallor ^ 
and  looks  dull  and  heavy,  as  in  typhus,  but  added  to  this 
there  is  a  curious  anxious  expression  about  the  eyes,  which 
is  accentuated  when  the  patient  is  touched.  The  eyes  are 
blood-shot,  and  the  skin  is  dry  and  burning.  The  tongue  is 
covered  with  a  thick  creamy  fur  which  rapidly  becomes 
brown,  and  sordes  form  on  the  lips  and  teeth.  Prostration  is 
extreme  and  the  voice  is  feeble.  The  patient  may  suffer  from 
delirium, usually  of  a  low  muttering  type, but  sometimes  violent,. 
or  he  may,  as  is  more  common,  sink  rapidly  into  a  typhoid 
state  of  stupor  and  prostration,  with  picking  at  the  bedclothes, 
suhsultus  tendinum,  and  retention  of  urine.  Vomiting  fre- 
quently occurs,  and  either  diarrhaia  or  constipation  may  be 
present.  The  pulse,  which  for  the  first  few  hours  may  have 
been  full  and  bounding,  becomes  soft  and  intermittent,  and 
the  first  sound  of  the  heart  is  weak  and  almost  inaudible.  The 
spleen  is  enlarged  and  frequently  the  liver  also.  The  urine 
is  scanty  and  high  coloured  and  may  contain  a  small  quan- 
tity of  albumin,  but  anything  in  the  nature  of  an  acute 
nephritis  is  rarely  met  with. 

Clinical  Types. — The  severity  and  duration  of  the  disease 
vary  very  much  in  different  epidemics  even  in  the  East,  and 
an  epidemic  of  plague  in  Western  and  Northern  Europe 
differs  greatly  from  that  met  with  in  the  warmer  climates 
and  the  unhygienic  surroundings  of  the  native  quarters  of 
towns  and  villages  in  China,  India  and  Southern  America. 
Among  white  races  living  in  sanitary  dwellings  in  a  tem- 
perate climate,  plague  tends  to  be  less  virulent  and  more 
chronic  in  its  course  than  is  usual  in  sub-tropical  countries. 


74  Chapter  IV. 

and  the  danger  of  a  large  epidemic  is  slight  since  the  winter 
and  spring  are  too  cold  to  favour  the  activity  of  the  B. 
pestis  which  has,  besides,  no  such  nidus  of  filth  as  is  met  with 
in  any  Eastern  town.  But  the  difference  is  merely  one  of 
degree— plague  in  Western  Europe  or  in  the  United  States 
of  America  is  simply  plague  in  Hong  Kong  watered  down — 
the  manifestations  are  the  same,  though  less  severe,  and  the 
clinical  types  are  identical.  The  tendency  to  chronicity  was 
notable  in  the  Glasgow  epidemic,  when  crisis  occurred  in  one 
case  18  days  after  the  onset  of  the  disease,  and  when  two  of 
the  ultimately  fatal  cases  survived,  one  to  the  40th  and 
another  to  the  44th  day. 

In  nine-tenths  of  all  cases  of  plague  the  type  is  bubonic, 
i.e.,  in  addition  to  the  conditions  described  above  as  belonging 
to  the  "stage  of  fever,"  visible  swelling  and  inflammation  of 
one  or  another  of  the  more  superficial  groups  of  lymphatic 
glands  occur,  forming  the  typical  "bubo."  The  buboes  are 
most  often  single,  and  appear  in  one  groin  in  a  large  per- 
centage of  cases,  but  they  may  appear  on  both  sides.  They 
may  also  appear  in  the  axilla,  and,  chiefly  in  children,  at  the 
lower  angle  of  the  jaw.  Small  buboes  have  been  seen  in  the 
root  of  the  neck,  the  sub-occipital  region,  and  in  the  bend 
of  the  elbow,  but  buboes  in  these  situations  are  extremely 
uncommon.  The  buboes  vary  very  much  in  size,  from  a  hazel- 
nut to  the  size  of  one's  fist.  They  are  usually  reddened  on 
the  surface,  painful,  tender  on  manipulation,  and  are  often 
surrounded  by  a  brawny  area  of  infiltration  both  of  skin  and 
connective  tissue.  The  bubo  makes  its  appearance  at  some 
time  between  the  first  and  fifth  day  of  the  stage  of  fever,  most 
commonly  during  the  first  day. 

In  faA^ourable  cases  after  a  very  variable  period  of  fever 
the  symptoms  begin  to  abate  and  the  first  indication  of  better- 
ment may  be  the  occurrence  of  a  profuse  sweating.  The  tem- 
perature begins  to  fall,  the  pulse  to  recover  its  tone,  the 
tongue  to  clean,  and  the  patient  becomes  sensible  and  in- 
telligent. But  the  bubo  does  not  subside  with  the  other 
symptoms.  In  most  instances  it  softens  and  suppurates,  and, 
if  left  to  itself  discharges  through  a  necrosed  area  of  skin  a 
quantity  of  very  foul  smelling  pus  mixed  with  sloughs.  When 


The  Plague.  '  75 

it  does  not  suppurate  it  may  take  months  to  disappear.  The 
healing  of  a  burst  or  incised  bubo  is  a  very  tedious  process 
and  may  prolong  convalescence  for  many  weeks.  In  a  small 
minority  of  cases  convalescence  is  rapid.  If  death  occurs,  it 
does  so  usually  within  the  first  week  of  the  disease,  from 
beart  failure,  profound  asthenia,  and  coma,  sometimes  with 
convulsions.  But  in  some  cases  life  is  prolonged  past  the 
subsidence  of  the  more  acute  manifestations  of  the  disease, 
and  death  may  occur  from  asthenia  after  prolonged  sup- 
puration of  one  or  more  buboes. 

The  other  clinical  types  usually  recognised  are  the 
septiccemic  and  'pneumonic  forms  of  the  disease. 

In  the  typical  septiccBTnic  form  no  enlargement  of  lym- 
phatic glands  is  visible  during  life,  and  the  signs  of 
illness  are  fever,  very  often  slight,  profound  exhaustion, 
delirium,  stupor  and  coma,  with,  in  a  fair  number  of  cases, 
haemorrhages  into  the  skin  and  from  the  bowels  or  other 
mucous  membranes.  In  these  cases  the  bacilli  are  found  in 
large  numbers  in  the  blood.  Diarrhoea  is  a  common  feature 
in  the  septicsemic  form  of  plague,  and  an  intestinal  form  of 
the  disease  is  sometimes  described.  There  is  little  doubt  but 
that  the  first  cases,  which  were  unrecognised,  occurring  in 
the  Glasgow  epidemic  of  1900  belonged  to  this  intestinal 
variety  of  the  septicsemic  form.  Death  usually  occurs  in 
septicEemic  plague  between  the  first  and  third  day  of  the 
disease,  and  this  form  is  very  dangerous  to  the  community,  as 
unless  it  occurs  in  the  middle  of  an  epidemic  it  is  seldom 
recognised  as  plague,  until  the  occurrence  of  attacks  of  the 
bubonic  form  among  those  who  have  been  in  contact  with  the 
patient  makes  it  plain  what  his  illness  has  been. 

There  is,  however,  a  somewhat  modified  form  of  the  sep- 
ticsemic type  which  appears  particularly  in  temperate  coun- 
tries and  in  which,  while  the  bacilli  are  found  in  the  blood- 
stream, the  attack  is  characterised  by  slight  enlargement  of 
the  superficial  lymphatic  glands,  so  that  small  masses  of 
glands  may  be  seen  in  the  groin,  axillse  and  neck.  In  this 
class  of  case  the  small  buboes  are  always  inultiple.  The  mor- 
tality in  this  somewhat  modified  form  of  the    septicsemic  type 


76  Chapter  IV. 

is  rather  less  than  in  that  which  shows  uo  lymphatic  enlarge- 
ment, but  is  far  in  excess  of  the  death-rate  from  the  true 
bubonic  variety. 

Pneumonic  pJague  is  the  most  directly  infectious  of  all 
the  forms  of  plague,  as  the  bacilli  are  discharged  in  great 
numbers  in  the  sputum,  and  it  is  also  an  extremely  fatal  form 
of  the  disease,  death  occurring  usually  between  the  third  and 
fifth  day  of  illness. 

The  symptoms  of  invasion  are  severe  and  the  tempera- 
ture rises  rapidly  to  high  registers.  The  patient  is  short  of 
breath,  and  troubled  by  a  frequent  cough  and  profuse  rather 
watery  blood-stained  sputum,  not  viscid  and  "rusty"  like  the 
sputum  in  an  ordinary  acute  pneumonia.  Signs  of  con- 
solidation of  the  lung  are  not  well  marked,  but  there  may 
be  some  dullness  on  percussion  at  one  or  both  bases  behind, 
with  great  diminution  of  the  volume  of  the  respiratory 
murmur  and  much  intra-pulmonary  crepitus.  Respiration  is 
very  rapid.  As  in  the  septicsemic  form  there  is  great  danger 
to  the  community  in  such  cases  when  they  occur  at  the 
beginning  of  an  epidemic,  since  there  is  little  to  indicate 
clinically  that  they  are  anything  more  than  extremely  malig- 
nant cases  of  acute  pneumonia,  and  the  infection  may  thus  be 
spread  widely  before  the  disease  is  recognised  as  plague. 

Another  form  which  often  appears  at  the  beginning  or 
end  of  an  epidemic  of  true  plague,  but  which  has  been  noted 
as  occurring  in  great  numbers  in  the  course  of  certain 
epidemics,  is  the  'pestis  Tninor,  or  ambulatory  form  of  plague. 
It  is  characterised  by  slight  malaise,  headache,  a  little  fever, 
and  the  occurrence  of  small  buboes  which  do  not  suppurate. 
It  is  easily  seen  how  such  cases  anay  spread  the  disease,  and 
their  recognition  is  of  the  greatest  importance. 

Diagnosis.  —  The  only  reliable  method  of  diagnosis  is 
by  the  recovery  of  the  infecting  organism  from  the  bubo,  the 
blood,  the  stools,  or  the  sputum.  Nothing  but  a  bacterio- 
logical examination  can  separate  plague  from  adenitis  of 
other  kinds  associated  with  fever,  when  they  occur  in  a  dis- 
trict where  plague  is  common  or  in  the  course  of  an  epidemic. 


The  Plague.  11 

It  will  be  iiece,ssary  to  differentiate  bubonic  swellings  of  all 
kinds,  whether  cervical,  axillary  or  inguinal,  when  plague  is 
epidemic,  and  cases  of  tuberculous  adenitis,  pyogenic  infec- 
tion of  glands  and  venereal  bubo  will  all  be  suspected.  The 
puncture  of  a  bubo  and  the  withdrawal  of  some  of  the  fluid  by 
a  syringe  with  due  antiseptic  precautions,  and  the  examina- 
tion of  the  fluid  by  staining  or  culture,  is  the  only  method  by 
which  plague  can  be  accurately  detected.  Fortunately  the 
bacillus  pestis  is  large  and  stains  well  with  the  ordinary  anilin 
stains,  such  as  Gentian  Violet,  and  it  is  usually  easily  recog- 
nised from  a  stained  smear-preparation  made  directly  from  a 
bubo.  The  short  thick  bacilli,  staining  with  a  "cap"  at 
either  pole  with  a  clear  space  between,  present  a  very  typical 
appearance.  A  culture  on  peptone-agar  should  be  made  at 
the  same  time  and  incubated  at  37°  C.  for  18  hours,  but  it  is 
to  be  remarked  that  in  cases  which  have  been  ill  for  some 
time  before  examination,  especially  when  the  bubo  is 
beginning  to  soften,  a  somewhat  degenerated  and  badly- 
staining  organism  may  be  seen  in  a  smear-preparation,  but  a 
culture  may  be  sterile.  When  any  doubt  remains  after 
examination  by  culture  and  staining,  inoculation  of  a  rat 
should  be  performed. 

The  differential  diagnosis  of  plague,  apart  from  the 
occurrence  of  bubonic  swellings,  is  clinically  impossible 
without  bacteriological  examination.  In  temperate  climates 
it  may  be  confused  with  typhus,  which  is  the  only  one  of 
our  common  infectious  fevers  to  which  it  bears  any 
resemblance,  unless  the  type  be  "intestinal"  or  "pneumonic." 
In  the  Glasgow  epidemic  of  1900,  the  early  cases  which  were 
not  sent  to  the  Fever  Hospital  were  "intestinal"  in  type  and 
were  labelled  "Zymotic  enteritis,"  while  the  first  three 
Avhicli  were  brought  to  Hospital  were  certified  "Enteric  (?)  " 
and  had  well  marked  buboes.  In  Suffolk,  during  the  autumn 
of  1910,  the  first  cases  were  pneumonic  in  type  and  were, 
most  naturally,  not  recognised  as  other  than  a  very  virulent 
pneumonia.  It  is  most  unlikely  that  a  severe  case  of  bubonic 
plague  will  be  mistaken  for  anything  else,  but  a  mild  case 
with  bubo  in  the  groin  can  only  be  distinguished  from  a 
venereal  bubo  by  the  discovery  of  the  B.  pestis. 


78  Chapter  IV. 

Complications. —  Tlie  complications  of  plague  are  not  at  all 
numerous.  Those  wliich  do  occur  are  usually  in  association 
with  pyogenic  infections,  resulting  from  the  suppuration  of 
the  bubo,  such  as  metastatic  abscesses  and  pleurisy. 

In  the  Glasgow  epidemic  of  1900  we  observed  one  case 
with  an  axillary  bubo  where  death  resulted  after  the  forma- 
tion of  a  large  abscess  under  the  pectoral  muscle  from  which 
we  recovered  the  pneumococcus. 

Sequelae. —  Beyond  a  prolonged  and  troublesome  con- 
valescence with  much  anaemia  and  muscular  weakness,  the 
sequelae  of  plague  are  unimportant. 

Treatment. — The  treatment  of  plague  apart  from 
the  use  of  antitoxic  serum  consists  mainly  in  the  main- 
tenance of  strength  by  rest  and  judicious  stimulation  with 
alcohol  and  strychnine  and  the  procuring  of  sleep  and  relief 
from  pain  by  the  use  of  small  doses  of  opium,  either  hypoder- 
mically  in  doses  of  ^  gr.  of  morphine,  or  by  the  mouth  in 
the  form  of  Battley's  solution  in  doses  of  5  min.  every  two 
or  three  hours  until  quiet  is  induced.  The  bubo  must  be 
carefully  tended ;  the  skin  over  it  should  be  gently  cleansed 
with  soap  and  water,  sponged  with  spirit  each  day,  and 
covered  with  a  layer  of  Gamgee's  tissue  after  powdering. 
When  softening  occurs  and  a  necrotic  area  of  skin  appears, 
it  is  well  to  open  the  swelling  freely  to  allow  of  sufficient 
drainage,  and  a  discharging  bubo  must  be  dressed  with  the 
strictest  antiseptic  precautions. 

Antitoxic  Serum  has  been  prepared  by  Yersin,  Calmette 
and  Borrel,  but  the  effectiveness  of  these  has  not  been  proved 
in  India  and  China,  except  when  Tersin's  serum  was  first  used 
in  Hong  Kong.  On  that  occasion  twenty-four  out  of  twenty- 
six  treated  cases  recovered. 

It  is  possible,  however,  that  in  temperate  climates  anti- 
toxic serum  may  prove  effective,  if  a  more  powerful  and  pro- 
perly standardised  serum  is  prepared.  Apart  from  serum 
treatment  one  feels  very  powerless  in  the  presence  of  a  disease 
so  virulent  and  rapid  in  its  course  as  plague,  and  all  other 


The  Playue.  79 

treatment  is  frankly  palliative  and  unsatisfactory.  Our  cases 
in  Glasgow  were  too  few  to  make  our  observations  on  the 
effect  of  serumtherapy  of  mucli  value,  but  our  impression  was 
that  in  cases  where  we  had  a  little  time  afforded  us  it  was  an 
aid  to  recovery,  and  that  after  the  use  of  Yersin's  serum  tlie 
patients  rallied  somewhat  and  were  more  comfortable,  the 
most  reliable  happenings  being  that  the  pain  of  the  bubo 
became  less  and  profuse  sweating  often  followed  the  injection. 
The  best  results  undoubtedly  followed  the  giving  of  40  ccm. 
of  serum  intravenously,  and  this  dose  may  probably  be  in- 
creased with  advantage. 

Epidemiology. — Plague  is  endemic  in  India,  China 
and  Uganda.  It  has  aj)peared  in  epidemic  form  in  Russia, 
Egypt,  Turkestan,  Japan,  the  Philippines,  Madagascar,  South 
Africa,  South  America,  San  Francisco,  and  Australia.  With 
the  exception  of  the  limited  epidemics  at  Oporto  in  1899, 
Glasgow  in  1900  and  1901,  and  Suffolk  in  1910,  plague  has 
not  appeared  in  Western  Europe  for  long,  save  for  the  occur- 
rence of  a  few  cases  here  and  there,  mostly  imported,  in  the 
great  seaport  towns.  On  the  whole,  plague  is  favoured  by  a  tem- 
perature that  is  neither  extremely  hot  nor  extremely  cold.  In 
Arabia,  epidemics  tend  to  decline  during  the  hot  and  dry 
summer,  and  in  temperate  climates  the  disease  usually  dies 
down  in  the  winter,  to  reappear,  may  be,  lat-e  in  the  following 
summer.  In  Glasgow,  the  disease  appeared  both  in  1900  and 
in  1901  during  the  month  of  August.  On  the  other  hand, 
the  plague  has  raged  through  the  extreme  heat  of  a  Hong 
Kong  summer,  and  has  survived  the  rigours  of  a  Russian 
winter. 

Method  of  Infection. — While  undoubtedly  directly  infec- 
tious, plague  is  not  nearly  so  much  so  as  scarlet  fever, 
measles,  or  smallpox,  and  it  is  extremely  rare  that  the 
attendants  in  a  clean  and  well-ventilated  hospital  acquire  the 
disease  from  the  patients  unless  they  are  dealing  with  the 
pneumonic  variety.  Unfortunately  cases  of  laboratory  infec- 
tion have,  however,  been  known  both  abroad  and  in  England. 
Where  attendants  on  the  sick  have  contracted  the  disease,  it 
has  usually  been  when  they  have  visited  the  patients  in 
squalid  and  verminous  homes,  or  when  the  patients  have  been 


so  Chapter  IV. 

allowed  to  wear  their  dirty  and  probably  flea-infested  clothing 
in  hospital,  or  when  the  attendants  have  been  careless  about 
abrasions  and  cuts  on  their  own  hands  or  faces.  Apaj't  from 
contact  with  infected  bedding,  clothing  or  furniture,  where 
irom  the  collection  of  filth  the  virus  has  been  unusually  con- 
centrated, it  seems  beyond  doubt,  after  the  work  done  by 
Lamb  at  Kassauli,  that  plague  is  spread  from  patient  to 
patient  by  means  of  fleas  and  other  vermin,  and  the  disease  is 
carried  on  by  rats  and  spreads  from  them  to  human  beings, 
•once  more  by  the  agency  of  fleas.  It  has  been  remarked  in 
"the  East  that  plague  among  rats  has  preceded  an  epidemic 
among  human  beings,  and  that  the  surviving  rats  will  leave 
a  district  in  which  other  rats  have  died  in  great  numbers  from 
"the  disease,  some  of  them  doubtless  carrying  infection  with 
"them.  In  temperate  climates  at  the  present  day,  plague 
must  be  imported  from  some  place  where  it  is  either  endemic 
•or  epidemic  at  the  time,  but  the  mode  of  entry  of  the  disease 
is  not  always  plain.  The  two  small  outbreaks  in  Glasgow  in 
1900  and  1901  are  of  extreme  interest,  because  no  definite 
case  of  plague  Avas  imported  at  the  beginning  of  the  first  out- 
break, nor  were  any  of  the  patients  known  to  have  been  in 
direct  contact  w^ith  foreign  shipping.  The  disease  arose  in  a 
squalid  part  of  the  town  from  no  definite  source  of  infection, 
as  it  might  do  in  any  other  large  city,  despite  all  the  precau- 
tions of  modern  health  administration.  The  second  outbreak 
in  the  following  year  arose  in  the  largest  Hotel  in  the  city  and 
was  traced  readily  to  rats  who  frequented  an  old  disused  sewer. 
'The  rats  were  found  to  have  plague  amongst  them  to  a  very 
considerable  extent,  and  it  is  likely  that  the  rats  were  first  in- 
fected during  the  epidemic  of  the  previous  year,  while  that  first 
epidemic  may  well  have  been  due  to  rats  infected  with  plague 
by  other  rats  who  had  come  from  abroad  on  board  ship. 

Period  of  Infectivity. — While  in  a  few  cases  the  B. 
pestis  has  been  found  to  have  disappeared  from  patients 
after  the  lapse  of  a  fortnight  from  the  commencement  of  the 
illness,  it  has  been  found  in  others  as  late  as  the  fifth  or  sixth 
week.  It  is,  therefore,  wise  to  consider  that  patients  who 
have  had  plague  are  infectious  for  at  least  six  weeks,  and  they 
•should  be  isolated  for  that  period. 


The  IHagne.  81 

Death  Rate. — The  death-rate  varies  greatly  in  ditterent 
epidemics,  even  in  the  East,  and  while  one  epidemic 
may  show  a  death-rate  of  90  per  cent,  among  those  attacked, 
another  may  show  a  death-rate  of  only  50  per  cent.  It  is 
astonishing  to  note  the  effect  of  nationality  on  death-rate  in 
the  East.  Manson  quotes  in  this  connection  the  figures  of  an 
epidemic  in  Hong  Kong  in  which,  while  "the  mortality 
among  the  indifferently  fed,  overcrowded,  unwashed  and 
almost  unnursed  Chinese  amounted  to  93.4  per  cent.,  it  was 
only  77  per  cent,  among  the  Indians,  60  per  cent,  among  the 
Japanese  and  18-2  per  cent,  among  the  Europeans,  a  grada- 
tix)U  in  general  correspondence  with  the  social  and  hygienic 
conditions  of  these  different  nationalities."  In  the  Glasgow 
epidemic  of  1900,  when  plague  appeared  among  the  lowest  of 
the  Irish  population,  the  hospital  death-rate  was  28"5  per 
cent.,  while  the  death-rate  among  all  cases  at  home  and  in 
hospital  was  rather  over  40  per  cent. 

Personal  Prophylaxis. — As  no  patient  suft'ering  from  plague 
can  be  treated  at  home  with  any  safety  to  the  com- 
munity, the  question  of  "  home  prophylaxis "  does  not 
arise.  But  something  falls  to  be  said  about  the  precautions 
to  be  taken  by  those  whose  work  it  is  to  tend  the  patients,  to 
investigate  suspicious  cases  and  to  work  in  the  infected  area. 
Nurses  and  physicians  must  hang  over  the  patients  as  little  as 
possible,  and  must  take  the  greatest  care  to  protect  any  cut  or 
abrasion  of  the  skin  with  an  impervious  dressing  of  collo- 
dion or  "  New-skin."  The  hands  should  be  washed  very 
frequently,  particular  care  being  taken  with  regard  to  the 
cleanliness  of  the  nails,  and  after  washing,  the  hands  should 
be  immersed  for  a  few  minutes  in  a  fairly  strong  solution  of 
permanganate  of  potash.  Stronger  antiseptics  are  not  desirable 
as  they  encourage  the  formation  of  cracks  in  the  skin,  and 
expose  the  attendant  to  the  risk  of  infection  through  an  in- 
jured epidermis.  The  nurse  should  see  that  the  patient,  if 
verminous,  is  freed  as  soon  as  possible  from  his  parasites, 
since  infection  by  them  is  a  dangerous  possibility.  No  food 
must  be  eaten  in  the  ward,  and  frequent  bathing  and  changing 
of  garments  is  essential. 


82  Chapter  IV. 

Those  who  are  engaged  iu  work  iu  an  infected  district > 
either  as  physicians,  inspectors,  or  on  the  disinfecting  staff, 
ought  to  wear  leggings,  as  the  legs  below  the  knee  are  the  most 
easily  accessible  portions  of  the  body  to  fleas,  and  the  hands 
should  be  washed  frequently  as  in  hospital.  Rat-catchers 
should  wear  gauntlets. 

Public  Health  Administration. — In  dealing  with  plague, 
as  with  smallpox,  it  is  necessary  not  only  to  isolate 
all  persons  who  have  fallen  victims  to  the  disease,  but 
to  segregate  carefully  all  "  contacts  "  until  the  maximum  in- 
cubation-period of  a  fortnight  has  elapsed.  In  Glasgow,  the 
patients  were  taken  to  the  Fever  Hospital,  and  all  the  "  con- 
tacts "  were  isolated  in  Reception  Houses  where  they  were 
under  constant  supervision  by  a  trained  staff  of  nurses  and 
visited  twice  daily  by  a  physician.  Their  temperature  was 
recorded  night  and  morning,  and  the  slightest  variation  from 
normal  health  was  reported  by  the  nurse  to  the  visiting  phy- 
sician at  any  time  of  the  day.  I  may  take  the  administration 
methods  of  the  Glasgow  Sanitary  Office,  carried  out  under  the 
supervision  of  Dr.  A.  K.  Chalmers,  as  being  applicable  to  any 
western  country  attacked  by  plague,  and,  instead  of 
stating  what  ought  to  be  done,  I  shall  state  what  was  done  in 
1900  as  being  as  effective  as  possible. 

The  following  routine  was  followed  during  the  epidemic  : 

1.  Within  the  infected  area  ashpits  were  emptied  thrice 
weekly  and  washed  once  a  week  with  chloride  of  lime 
solution. 

2.  Back  courts  were  hosed  every  night  with  chloride  of 
lime  solution. 

3.  A  special  inspection  of  the  district  was  undertaken  for 
the  detection  of  dirty  houses,  entries,  &c.,  and  for  the 
overcrowding   of  houses. 

4.  Medical  inspection  of  the  district  was  carried  out  and  the 

inhabitants  of  infected  buildings  and  all  "  contacts  " 
were  offered  injection  with  Tersin's  serum  or  Haffkine's 
vaccine,  while  all  suspected  cases  were  visited  with 
their  own  medical  attendants. 


Tlie  FUujue.  83 

5.  Handbills  were  distributed  offering  tlie  service  oi'  the 
medical  staff  at  any  time. 

6.  The  crews  of  all  ships  were  inspected  on  arrival  in 
port. 

7.  Fumigation  of  infected  liouses  was  carried  out  by 
liquified  SO 2  for  twelve  or  twenty-four  hours,  after 
which  the  house  was  entered  and  all  articles  of  bedding, 
clothing,  &c.,  were  wetted  with  a  2  per  cent,  solution 
of  formalin  (1  gallon  of  a  40  per  cent,  solution  of 
formaldehyde  to  50  gallons  of  water),  removed  to  the 
Sanitary  Wash-house,  and  then  boiled  or  steamed.  All 
articles  which  could  not  be  boiled  or  steamed  were 
burned. 

8.  All  houses  where  cases  had  occurred  or  from  which  con- 
tacts were  removed  were  sprayed  with  the  formalin 
solution,  as  were  also  the  lobbies  and  entries. 

9.  Clinical  demonstrations  Avere  given  daily  to  medical 
practitioners  at  the  hospital. 

10.  A  pamphlet  descriptive  of  the  varieties  of  the  disease 
was  distributed  among  the  medical  practitioners  of  the 
city. 

11.  Physicians  to  out-patients  at  the  various  hospitals  were 
specially  circularised. 

12.  A  campaign  against  rats  was  entered  upon;  rat-catchers 
were  engaged  and  the  bodies  of  rats  were  investigated 
for  the  signs  of  plague.  The  sewers  of  the  hospital 
were  treated  with  liquified  SO2,  and  the  rats  driven 
from  the  hospital  by  this  method. 

13.  The  bodies  of  those  who  died  from  plague  were 
drenched  with  formalin  and  enclosed  in  an  air-tight 
leaden  shell  before  burial. 

14.  As  the  epidemic  arose  among  the  Irish  Catholic  popula- 
tion, the  holding  of  wakes  over  any  dead  bodies  was 
prohibited,  thus  repeating  one  of  the  old  precautions 
taken  at  the  time  of  the  great  ravages  of  the  plague  in 
Glasgow  in  1646,  when  it  was  ordained  "that  ther  be 
na  meiting  at  lykwakes  nor  efter  burrials,  and  that 
this  be  intimat  by  touk  of  drume." 


G    2 


(    84    ) 


Chapter  V. 

CHOLERA. 

Synonyms. —  Cholera   morbus,    Asiatic   Cholera,   Epi- 
demic Cholera. 

Fr.  :      Cholera. 

Ger.  :      Cholera. 

Definition.  —  An  acute  speciiic  disease,  characterised  by 
violent  gastro-intestinal  symptoms,  propagated  by  water, 
running  a  short  course  and  occurring  in  epidemics, 
associated  with  an  organism  found  in  the  stools,  the  Cholera 
Vibrio,  or  Comma  bacillus,  discovered  by  Koch  in  1883. 

Incubation  Period. — This  varies  from  a  few  hours  to 
ten  days,  and  three  to  six  days  is  given  as  the  usual  incu- 
bation period. 

Rash. —  No  rash  has  been  observed  as  typical  of  the 
disease,  but  a  patchy  scarlatiniform  eruption  is  occasionally 
seen  during  the  stage  of  reaction. 

Clinical  Types.  —  Cholera  may  attack  a  patient  with 
great  suddenness,  or  may  be  preceded  by  certain  pro- 
dromal symptoms.  The  most  common  of  these  is  the  "pre- 
monitory diarrhoea,"  but  it  is  open  to  doubt  whether  this  is 
really  due  to  the  cholera  infection,  or  whether  it  is  not  due- 
to  a  simple  intestinal  catarrh  which  renders  the  bowel  more 
•s'uluerable  to  the  attack  of  the  cholera  germ.  Occasionally 
a  short  period  of  languor  and  depression  with  headache  and 
noises  in  the  ears,  precedes  the  true  onset  of  the  disease.  The 
first  symptom  of  cholera  is  the  passage  of  very  frequent, 
copious,  watery  stools,  which  is  not  accompanied  by  any  pain 
or  griping.     The  stools  very  quickly  lose  their  fsecal  character 


Cholera.  8  5 

and  take  on  the  "rice-water"  appearance  so  typical  of 
the  disease,  i.e.,  they  are  like  very  thin  rice-water  containing 
abundant  small  white  flakes.  Violent  v^omiting  soon  appears, 
at  first  of  food  taken  and  bile-stained  mucous  material,  but 
very  quickly  of  the  same  "rice-water"  material  as  is  passed 
by  the  bowel.  The  patient  now  presents  all  the  appearance  of 
profound  collapse — he  looks  shrunken  and  pinched,  the  eyes 
are  sunken  and  the  fingers  look  shrivelled,  while  the  skin 
generally  is  cold  and  covered  with  a  clammy  sweat,  respiration 
is  rapid  and  shallow  and  the  pulse  is  weak  and  fluttering  or 
may  be  altogether  absent.  The  urine  is  completely  sup- 
pressed. The  temperature  in  the  axilla  and  mouth  is  sub- 
normal, sometimes  as  low  as  93°  or  94°  F.,  but  at  the  same 
time  the  rectal  temperature  may  be  as  high  as  104°  F.  The 
patient  is  restless,  complains  of  intense  thirst,  and  suffers  ex- 
cruciatingly from  cramps  in  the  abdomen  and  extremities. 
His  mind  may  be  clear  although  apathetic,  or  he  may  sink 
rapidly  into  a  mild  delirium  followed  by  coma.  This  stage 
has  been  called  the  "  stage  of  collapse  "  or  "  algide  stage," 
and  may  terminate  in  death,  in  rapid  convalescence,  or  in  the 
stage  of  "  febrile  reaction." 

When  death  occurs  in  the  stage  of  collapse,  it  usually 
does  so  within  twenty-four  hours  of  the  onset  of  symptoms, 
and  may  occur  after  an  illness  of  only  two  or  three  hours. 

Sometimes  after  the  stage  of  collapse  having  lasted  for 
about  a  day,  the  purging  gradually  ceases,  the  body  becomes 
warm  again,  the  pulse  is  stronger,  the  urinary  flow  returns, 
bile  appears  in  the  motions,  and  in  a  few  days  the  patient  is 
well  again.  Much  more  commonly,  however,  the  "  algide 
stage  "  merges  into  the  "  stage  of  reaction.  "  As  this  stage 
is  entered  upon,  the  patient  becomes  warmer,  the  shrivelled, 
shrunken  look  disappears,  he  grows  less  restless,  ceases  to 
suffer  pain,  and  the  pulse  grows  stronger,  while  the  bowels 
move  less  frequently,  and  the  motions  begin  to  show  bile- 
staininff.  At  the  same  time  a  certain  amount  of  fever  makes 
its  appearance,  of  variable  degree,  rarely  rising  to  very  high 
registers.  In  some  cases  this  "febrile  reaction"  lasts  onlv 
for  a  few  hours,  at  the  end  of  which  the  fever  subsides  and 
convalescence  begins.     But  in  more  severe  cases  the  stage  of 


86  Cha'pter  Y. 

reaction  may  last  for  four  or  five  days  to  rather  over  a  fort- 
niglit,  during  which  the  patient  may  be  highly  febrile  and 
resemble  a  case  of  enteric  fever,  the  resemblance  having  struck 
some  observers  so  much  that  the  name  "cholera  typhoid" 
has  been  given  to  this  stage  of  the  disease.  The  patient's 
face  is  flushed,  and  the  fever  may  rise  even  to  hyperpyretic 
registers.  The  tongue  is  brown  and  dry,  low  delirium,  with 
some  tremor,  and  suhsultus  tendinuTn,  may  be  present,  or  the 
patient  may  sink  into  a  state  of  profound  stupor.  The  stools 
are  like  the  later  stools  in  enteric  fever,  greenish  or  "  pea- 
soup  "  in  character,  containing,  perhaps,  a  little  blood,  and 
are  commonly  very  offensive.  The  urine  may  remain  sup- 
pressed for  some  days,  even  as  long  as  six,  and  when  the  flow 
is  re-established  it  is  usually  scanty,  high-coloured  and  may 
be  highly  albuminous,  containing  abundant  casts.  In 
favourable  cases  the  symptoms  gradually  subside  in  about  a 
week,  the  urine  becomes  copious  and  less  albuminous,  and  the 
patient  becomes  convalescent.  In  cases  which  prove  fatal 
during  this  period,  death  often  results  from  a  profound  asthenia 
or  a  low  form  of  pneumonia.  Diarrhoea  may  again  become 
urgent,  and  the  patient  may  die  with  all  the  indications  of 
a  very  acute  enteritis.  Death  may  also  occur  after  convul- 
sions, or  profound  coma,  which  usually  occur  when  there  has 
been  delay  in  the  re-establishment  of  the  urinary  flow,  or  when 
the  urine  has  remained  very  scanty  and  albuminous. 

Cholera  sicca  is  the  name  which  has  been  given  to  a  very 
fatal  class  of  case  in  which  collapse  sets  in  with  great  rapidity 
and  in  which  there  is  almost  no  diarrhoea  or  vomiting,  and  no 
passage  of  "rice-water"  stools.  In  such  cases  'post-mortem 
examination  reveals  the  presence  of  large  quantities  of  rice- 
water  material  in  the  bowel,  although  none  has  been  passed 
during  life. 

Mild  forms  of  Cholera. — In  all  epidemics  mild  cases  are 
found,  in  which  there  is  diarrhoea  and  malaise  without  com- 
plete suppression  of  urine  or  the  occurrence  of  "  rice-water  " 
stools,  and  in  which  the  diarrhoea  is  not  accompanied  by 
cramps.  In  other  cases  the  typical  rice-water  stools  may  be 
present,   but  are  not  accompanied   by   suppression   of   urine, 


Cholera.  87 

while  the  cramps  may  be  not  at  all  severe.  In  these  mild 
forms  the  attack  subsides  quickly,  and  is  not  followed  by  any 
"  stage  of  re-actiori." 

Kelapse  in  Cholera. — In  a  certain  number  of  cases 
after  the  patient  begins  to  show  signs  of  "  reaction  "  a  relapse 
occurs,  and  the  patient  sinks  again  into  a  state  of  collapse 
and  purging.     Such  relapses  are  generally  fatal. 

Diagnosis. —  The  diagnosis  of  cholera,  especially  at  the 
beginning  of  an  epidemic,  is  not  always  an  easy  matter. 
Pungus-poisoning,  ptomaine-poisoning,  zymotic  enteritis,  and 
the  early  stage  of  trichinosis,  may  present  symptoms  ex- 
tremely like  Asiatic  cholera,  and  may  occur  in  more  or  less 
epidemic  form.  These  diseases  are  accompanied  by  diar- 
rhoea and  vomiting,  with  a  tendency  to  collapse,  and  the  stools 
may  resemble  very  closely  the  "rice-water"  evacuations.  It 
is  very  unusual,  however,  that  the  stools  are  as  deficient  in 
bile  as  in  a  severe  case  of  cholera,  and  "  rice-water  "  vomiting 
is  never  seen  in  other  diseases,  while  in  fungus-poisoning  por- 
tions of  the  fungus  eaten  may  be  seen  in  the  stools,  and  micro- 
scopic examination  of  the  dejecta  in  a  case  of  trichinosis  will 
reveal  the  presence  of  the  adult  worm.  The  great  difficulty 
in  differential  diagnosis  in  temperate  climates  is  between 
zymotic  enteritis  or  acute  gastro-enteritis  and  cholera,  and 
here  we  must  depend  largely  on  the  results  of  a  bacteriological 
examination  of  the  dejecta.  Films  may  be  made  directly 
from  the  stools,  but  it  is  best  to  make  cultures  from  one  of  the 
flakes  floating  in  the  liquid  stool.  After  placing  such  a  flake 
in  a  test  tube  of  Dunham's  solution  of  1  per  cent,  peptone  and 
•50  per  cent,  sodium  chloride,  and  incubating  for  some  6-10 
hours  at  37°  C,  the  upper  strata  of  the  fluid  will  be  found,  in 
most  cases  of  cholera,  to  show  an  abundant  growth  of  the 
characteristic  vibrio,  or  comma  bacillus. 

But,  as  the  bacillus  of  Tinkler  and  Prior  and  Deneke's 
vibrio  are  morphologically  practically  identical  with  the 
vibrio  of  cholera,  it  will  be  necessary  in  addition  to  try  to 
get  the  "  cholera-red  "  reaction,  which  is  obtained  by  adding 
a  few  drops  of  sulphuric  acid  directly  to  the  culture.  In  view 
of  the  necessity  for  accurate  differentiation  of  the  cholera 
vibrio,  it  is  wise  to  leave  the  bacteriological  examination  in 


88  Chapter  V, 

the  liaiuls  of  a  skilled  bacteriologist,  although  it  is  a  good 
thing  for  the  practitioner  to  make  a  film  from  the  suspected 
dejecta  and  search  directly  for  the  vibrio  after  staining  with 
fuchsin.  The  presence  of  any  vibrio  in  the  dejecta  makes  it 
necessary'-  to  have  a  further  examination  made.  It  is  to  be 
remembered  that  in  a  few  cases  of  cliolera  the  vibrio  may  not 
be  discovered,  just  as  in  a  certain  number  of  cases  of  pul- 
monary phthisis  careful  search  has  failed  to  reveal  the  pres- 
ence of  the  bacillus  of  tubercle  in  the  sputum  during  life,  so 
that  the  negative  result  of  a  bacteriological  examination  must 
not  be  taken  absolutely  to  mean  that  a  patient  does  not  suffer 
from  cholera. 

Complications. — The  complications  of  cholera  are  not 
numerous,  but  may  be  severe.  Occasionally  during  the 
second  week  pneumonia,  bronchitis  or  pleurisy  occurs,  or  some 
sloughing  of  the  fauces,  bladder,  or  sexual  organs,  or,  it 
may  be,  actual  gangrene  of  fingers,  toes,  ears  or  nose  takes 
place,  while  bed-sores  are  apt  to  occur.  A  troublesome  com- 
plication is  ulcer  of  the  cornea,  which  may  occur  early  in  the 
"stage  of  reaction."  The  lower  part  of  the  cornea  is  that 
which  is  usually  affected,  and  the  beginning  of  the  process  is 
characterised  by  a  cloudy  opacity  in  the  cornea,  covered,  per- 
haps, with  some  exuded  lymph.  Ulceration  quickly  follows, 
and  perforation  may  result,  and  as  a  rule,  if  the  patient  re- 
covers, the  eye  is  destroyed.  Sometimes  during  the  second  or 
third  week  an  acute  suppurative  parotitis  occurs  which  seri- 
oasiy  interferes  with  the  patient's  taking  food,  and  is  always 
an  ominous  sign. 

Sequelae.  —  The  common  sequelae  of  cholera  are  anaemia, 
mental  and  physical  weakness,  insomnia,  enteritis,  coli- 
tis, and  nephritis.  In  most  cases  which  have  recovered 
after  passing  through  a  severe  "stage  of  reaction"  con- 
valescence is  protracted  and  many  months  may  elapse  before 
the  patient  recovers  his  ordinary  strength. 

Treatment. — So  far,  as  the  death-rate  shows,  the  treat- 
ment of  cholera  has  been  most  unsatisfactory.  It  is 
purely  symptomatic,  as  no  anti-cholera  serum  or  vaccine  has 
been    discovered    for    curative    purposes.       In    the    stage    of 


Cholera.  89» 

premonitory  diarrlioea,  or  very  early  in  the  stage  of  "  rice- 
water"  purging-,  opium,  given  as  laudanum  or  chlorodyrie  in 
large  doses  combined  with  brandy,  is  often  very  efficacious  in 
checking  the  loss  of  fluid,  and  even  in  tHe  "  stage  of  collapse" 
the  use  of  morphine  hypodermically  in  doses  of  J-|  of  a  grain 
is  not  to  be  discouraged.  But  where  the  "  stage  of  collapse  "  or 
"  algide  stage"  is  fully  established,  the  treatment  first 
recommended  by  Cox  of  Woosung,  and  modified  by  Leonard 
Eogers  of  Calcutta,  is  worthy  of  serious  trial.  In  view  of  the 
fact  that  many  of  the  most  dangerous  symptoms  in  cholera 
are  due  to  the  loss  of  fluid  by  the  bowel.  Cox  recommended 
the  continuous  slow  intravenous  injection  of  normal  saline 
solution,  allowing  the  fluid  to  flow  by  gravity  from  a  vessel 
placed  about  a  couple  of  feet  above  the  level  of  the  point  of 
injection,  continuing  the  process  so  long  as  any  danger  of  col- 
lapse was  present. 

Leonard  Rogers  published  his  results  of  intravenous 
saline  injections  in  the  British  Medical  Journal  of  Sept,  24th, 
1910.  He  uses  a  "  hypertonic  "  saline  solution,  consisting  of 
120  grains  of  sodium  chloride,  6  grains  of  potassium  chloride 
and  4  grains  of  calcium  chloride  to  a  pint  of  sterile  water. 
Soluble  tablets  for  the  making  of  this  solution  may  be  obtained 
from  both  Messrs.  Burroughs,  Wellcome  and  Co.,  and  Parke, 
Davis  and  Co.  Where  the  rectal  temperature  is  hyperpyretie 
the  solution  should  be  injected  at  a  temperature  not  exceeding- 
98-4°,  or  even  somewhat  lower.  When  collapse  is  marked,, 
three  or  four  pints  may  be  given  at  the  rate  of  four  ounces 
per  minute,  and  the  rate  should  be  slowed  to  one  ounce  per 
minute  if  the  patient  complains  of  headache  or  other  distress. 
The  specific  gravity  of  the  blood  should  be  taken  before  the 
commencement  of  this  treatment,  as  the  amount  of  fluid  in- 
jected ought  to  be  regulated  by  the  height  of  the  specific 
gravity,  as  collapse,  simulating  cholera,  but  without  a  high 
specific  gravity  of  the  blood,  will  not  be  helped  by  intra- 
venous injections,  but  the  reverse.  Rogers  found  that  his- 
results  with  intravenous  injections  were  better  than  with  in- 
tracellular and  rectal  injections,  but  has  found  that  he  has 
obtained  his  best  results  by  a  combination  of  intravenous- 
"  hypertonic  "  injections  and  the  giving  of  permanganates  by 


90  Chapter  V. 

the  mouth.  He  gives  permanganate  of  calcium  in  solution, 
(^-1  grain  to  the  pint  of  water,  increased  rapidly  by  4-6  grains 
to  the  pint)  and  encourages  the  patient  to  drink  as  much  as 
possible  in  the  day.  Vomiting  is  seldom  induced  by  this 
treatment  and,  indeed,  is  often  checked  by  it.  In  other 
cases  he  has  given  the  permanganate  of  potash  in  doses  of  2 
grains  in  the  form  of  a  pill  made  up  with  as  little  kaolin  and 
vaseline  as  possible  and  coated  with  a  varnish  composed  of 
one  part  of  Salol  and  five  parts  of  Sandarach  varnish.  The 
pills  must  be  absolutely  fresh.  One  pill  should  be  given 
every  quarter  of  an  hour  for  the  first  two  hours,  and  then 
every  half  hour  until  the  stools  are  green  and  less  copious, 
which,  Rogers  states,  occurs  in  about  twelve  hours.  At  the 
beginning  of  the  second  day  eight  more  pills  should  be  given 
with  the  same  intervals,  and,  in  severe  cases,  eight  more  at 
the  beginning  of  the  third  day,  to  prevent  relapse.  Barley 
water  may  be  given  to  the  patient  during  treatment  with  the 
permanganate  pills. 

Vomiting  may  be  relieved  by  sips  of  iced  water  or  small 
quantities  of  iced  champagne.  The  cramps  can  often  be 
alleviated  by  friction  by  the  hand  with  some  A. B.C.  Liniment 
or  other  mild  rubefacient,  or,  if  unrelieved  by  such  treat- 
ment, may  demand  the  hypodermic  injection  of  morphine,  or 
even  the  inhalation  of  chloroform.  The  patient  must  be 
kept  warm  and  absolutely  at  rest;  the  use  of  a  warmed  bed 
pan  must  be  insisted  on,  since  the  exertion  of  rising  to  go  to 
stool  is  most  dangerous. 

Calomel  in  small  doses,  as  in  enteric  fever,  has  been  re- 
commended by  some,  and  the  whole  gamut  of  astringents  has 
been  tried,  but  it  is  plain  that  in  large  numbers  of  cases  of 
cholera  vomiting  prevents  the  employment  of  either  oral 
medication  or  alimentation.  In  the  same  way  the  profuse 
diarrhoea  makes  any  attempt  at  rectal  medication  equally  im- 
possible, so  that  hypodermic,  intracellular,  and  intravenous 
methods  will  be  found  in  many  instances  to  be  the  only  ones 
possible. 

If  the  pulse  fail  at  the  wrist,  the  hypodermic  injection  of 
alcohol  or  ether  may  spur  it  on  for  a  little,  and  a  single  in- 
travenous or  intracellular  injection  of  a  pint  of  saline  solution 


> 


Cholera.  91 

may  bring  temporary  improvement,  but  if  the  saline  injec- 
tions are  to  be  eifective  they  ought  to  be  given  slowly  and  con- 
tinuously and  not  intermittently,  and  it  is  better  to  try  to 
prevent  the  occurrence  of  serious  cardiac  failure  by  beginning 
such  injections  early  in  the  disease  than  to  institute  them 
when  failure  of  the  heart  has  begun  already  to  render  absorp- 
tion even  from  the  lymph-spaces  extremely  slow  and  difficult. 

If  the  urine  be  suppressed  after  the  first  day  of  the  stage 
of  reaction,  it  is  viell  to  stimulate  its  secretion  by  hot  appli- 
cations to  the  loins,  or  by  the  application  of  dry  cups  to  the 
lumbar  region  followed  by  a  hot  poultice  or  fomentation. 
Careful  examination  should  be  made  for  distended  bladder,  as 
sometimes  after  a  period  of  suppression  of  urine  it  is  retained 
by  an  atonic  and  insensitive  bladder  after  the  re-establish- 
ment of  secretion.  Should  the  bladder  be  found  distended, 
the  catheter  should  be  used  at  once. 

If  in  the  stage  of  reaction  there  should  still  be  much 
purging,  large  doses  of  the  salicylate  of  bismuth  should  be 
given  with  a  little  powdered  opium.  The  rectal  injection  of 
large  quantities  of  tannin  in  mucilage  is  sometimes  of  ser- 
vice in  obstinate  diarrhcea,  and,  as  in  enteric  fever,  the  care- 
ful irrigation  of  the  lower  bowel  with  hot  water,  using  a  soft 
tube,  may  cure  the  condition.  Should  the  patient  be  con- 
stipated, no  purgatives  should  be  given,  but  movement  of 
the  bowels  should  be  secured  by  the  rectal  injection  of  soap 
and  water. 

When  corneal  ulcer  occurs,  the  eye  should  be  bathed  fre- 
quently with  warm  soda-bicarbonate  solution  or  treated  with 
some  of  the  albuminous  salts  of  silver,  while  touching  the 
edge  of  the  ulcer  with  the  galvano-cautery  may  stay  the  pro- 
cess. 

Sloughing  of  the  fauces  should  be  treated  by  careful  spray- 
ing of  the  throat  with  some  mild  antiseptic,  and  sloughing  of 
the  bladder  by  rest  and  bland  diuretics  in  combination  with 
small  doses  of  tincture  of  belladonna,  1  or  2  minims,  every 
hour.  Gangrene  and  parotitis  fall  to  be  dealt  with  sur- 
gically. The  treatment  during  convalescence  is  mainly 
dietetic,  but  persistent  ansemia  will  be  helped  by  the  use  of 
iron  and  arsenic,  nervous  symptoms  by  rest  and  change  of 


92  Chapter  V. 

scene  and  the  use  of  the  bi-omides  combined  with  belladonna 
and  mix  vomica,  while  enterocolitis  may  be  relieved  by  a  bland 
dietary  or  the  giving  of  powdered  ipecacuanha  with  very 
small-  doses  of  calomel  and  regular  irrigation  of  the  lower 
bowel.  The  treatment  of  nephritis  is  too  well  known  to  need 
comment. 

Diet. —  During  the  algide  stage,  all  food  should  be 
withheld.  Thirst  may  be  quenched  by  sips  of  iced  water  if 
vomiting  is  not  induced  by  small  quantities  of  fluid  taken  by 
the  mouth,  but  the  use  of  saline  by  continuous  intravenous  or 
intracellular  injections  Avill  be  found  to  quench  thirst  almost 
as  well  as  sips  of  water  by  the  mouth,  and  insures  at  the  same 
time  a  replacing  of  some,  at  least,  of  the  fluid  lost  by  the 
bowel.  During  the  "  stage  of  reaction  "  and  in  "  cholera 
typhoid  "  the  diet  must  be  fluid  and  extremely  bland.  Milk 
diluted  with  barley-water  or  rice-water,  with  a  little  clear 
soup  or  meat-juice,  should  form  the  entire  diet  of  the  patient 
during  these  periods,  since  errors  in  diet  may  induce  relapse, 
or  at  least  a  very  troublesome  diarrhoea.  During  the  estab- 
lishment of  convalescence  a  mixed  diet  should  be  quite  as 
carefully  resumed  as  in  enteric  fever,  and,  indeed,  the  resump- 
tion may  be  Math  advantage  even  more  gradual,  as  the  future 
health  of  the  intestine  depends  largely  on  careful  feeding 
during  convalescence. 

Epidemiology. — As  a  rule  cholera  appears  in  temper- 
ate climates  during  the  summer  months  and  disappears 
as  winter  advances,  but  it  has  been  known  to  survive  the  cold 
of  a  Russian  winter.  In  Europe  the  later  epidemics  have 
been  definitely  spread  by  water-supply,  as  is  instanced  by 
the  epidemic  in  Hamburg  in  1892-93,  and  the  Naples  epi- 
demic of  1883.  The  danger  of  an  impure  water-supply  was 
very  well  exemplified  in  the  Hamburg  epidemic.  Hamburg 
and  Altona  are  practically  one  town  (in  one  part  the  boundary 
between  the  two  is  simply  a  street),  but  at  the  time  of  the 
epidemic  Hamburg  was  more  or  less  an  independent  town, 
■while  Altona  was  Prussian.  Both  drew  their  water-supply 
from  the  Elbe,  but,  while  Altona  had  an  elaborate  system  of 
filter  beds,  Hamburg  had  none,  and  the  water  was  pumped 


Cholera.  93 

straight  into  the  main  from  the  river.  T}ie  result  was  that 
Hamburg  suffered  severely,  while  the  cases  in  Altona  were 
lew,  showing  that  tlie  disease  was  definitely  water-borne,  since 
the  communication  between  the  two  towns  both  commercially 
and  socially  is  considerable,  and,  had  the  disease  been  com- 
municated chiefly  by  contact  and  aerial  convection  like  small- 
pox, the  two  towns  would  not  have  suffered  so  dispropor- 
tionately. The  causal  agent  is  in  the  stools,  and  patients  may 
of  course,  infect  those  surrounding  them  by  the  dejecta,  and 
defectiA^e  drainage  may  spread  the  disease  through  a  limited 
area,  but  when  the  water  supply  is  good  and  free  from  all 
risk  of  contamination,  it  is  not  probable  that  an  epidemic  will 
attain  any  very  great  proportions.  There  is  no  doubt  that 
the  cholera  vibrio  is  at  least  a  necessary  adjunct  to  the  ac- 
quirement of  the  disease,  but  from  laboratory  experiments  it 
has  been  shown  that  large  quantities  of  the  vibrio  in  culture 
may  be  swallowed  with  impunity.  But  the  laboratory  pure 
culture  may  be  a  very  different  thing  to  the  bacillus  in  the 
ground,  and  we  do  not  know  what  symbiotic  influence  may  be 
required  for  the  acquirement  of  a  virulence  necessary  for  the 
production  of  an  epidemic.  That  such  a  virulence  must  be 
acquired  outside  the  body  is  shown  by  the  fact  that  at  the 
beginning  of  an  epidemic  the  cases  tend  to  be  acute,  short 
and  fatal,  while  as  the  epidemic  proceeds  the  attacks  tend  to 
be  milder  and  of  longer  duration.  Among  the  causes  which 
contribute  to  an  attack  of  cholera  must  be  mentioned  chill, 
irregular  living,  errors  in  diet,  and  fear.  The  last  is  no  mere 
Action  of  the  imagination.  I  have  heard  the  same  story  re- 
jaeatedly  from  men  who  have  seen  service  in  the  East,  both 
physicians  and  others,  that,  in  their  experience,  fear  is  one  of 
the  most  powerful  predisposing  causes  of  an  attack  of  cholera, 
and  when  it  is  remembered  how  fear  and  worry  tend  to  lower 
vitality,  it  is  not  surprising  that  this  should  be  the  case. 

Period  of  Infeetivity. — The  discharges  of  a  patient 
w4io  has  had  cholera  may  remain  infectious  up  to 
about  seven  weeks  from  the  onset  of  the  illness,  althousrh  in 
mild  cases  they  may  be  free  from  the  vibrio  in  two  or  three 
weeks,  and  it  is  wise  to  consider  a  patient  infectious  until  the 
vibrio  can  be  no  longer  discovered  in  the  stools. 


94  Chapter  V. 

Death-Rate. — The  average  death-rate  in  all  epidemics 
is  calculated  at  about  50  per  cent,  of  cases  attacked, 
but  it  is  much  higher  in  some  epidemics,  while  in  others 
it  is  considerably  less.  Much  depends  on  the  condition  of 
those  attacked.  The  old,  the  very  young,  pregnant  women, 
those  who  suffer  from  disease  of  the  heart,  liver  or  kidneys, 
the  naturally  feeble,  the  poorly  fed,  and  the  alcoholic,  die  in 
great  numbers. 

Personal  Prophylaxis. — As  in  plague,  no  patient  ought, 
in  civilised  western  countries,  to  be  nursed  at  home, 
whatever  be  his  social  position,  so  that  discussion  of 
"  home  prophylaxis  "  does  not  fall  to  be  made.  Those  in 
attendance  on  the  sick  should  take  the  same  precautions  as  in 
enteric  fever,  and  the  same  scrupulous  care  should  be  adopted 
in  the  disinfection  of  the  dejecta,  vomited  material,  and 
all  vessels  and  clothing  which  have  been  in  contact  with 
the  patient.  Food  must  never  be  eaten  in  the  ward,  and  the 
hands  should  be  most  carefully  cleaned  after  touching  the 
patient.  Those  living  in  a  district  in  which  cholera  has  ap- 
peared should  pay  the  strictest  attention  to  personal  and 
household  cleanliness,  and  must  live  most  carefully  in  every 
way.  Fruit  and  cucumber  which  has  travelled  at  all  should 
not  be  eaten,  as  the  possibility  of  "  carried  "  fruit  causing 
diarrhoea  is  well  known,  and  anything  which  encourages 
gastro-intestinal  catarrh  predisposes  to  cholera.  The  domestic 
water-supply  must  be  enquired  into,  and  it  is  better  during  an 
epidemic  of  cholera  to  drink  no  fluid  which  has  not  been  thor- 
oughly boiled.  Manson  most  sensibly  recommends  that  during 
an  epidemic  the  drink  of  a  household  should  consist  of  weak 
tea  and  decoction  of  lemon,  for  both  of  which  boiling  water 
is  necessary.  Aerated  waters  should  be  avoided  except  such 
as  are  manufactured,  like  those  of  the  "  Salutaris"  company, 
from  distilled  water.  If  aerated  waters  are  manufactured  with 
a  basis  of  distilled  water  and  in  hygienic  surroundings,  they 
are  quite  incapable  of  conveying  infection  so  long  as  the 
syphons  and  their  fittings  are  cleaned  both  inside  and  out 
with  steam,  under  pressure,  before  being  refilled. 

Public  Health  Administration. — All  persons  must  be  isolated 
in    a     suitable    Hospital     or     camp,     according     to     district 


Cholera.  95 

uiid  climate,  and  all  "  contacts "  if  not  segregated  in 
Reception  Houses  ought,  at  least,  to  be  kept  under  the 
strictest  medical  supervision  in  their  own  homes.  The  dis- 
trict in  which  the  outbreak  has  occurred  should  be  subjected 
to  the  most  rigorous  scrutiny,  and  its  water-supply,  drainage, 
and  general  cleanliness  promptly  attended  to  if  in  any  way 
defective.  There  are  few  towns  in  Great  Britain  where,  from 
the  condition  of  water-supply,  a  large  water-borne  epidemic 
is  likely  to  break  out,  since  when  the  supply  is  from  an  ad- 
jacent river  the  water  is  filtered  before  it  is  distributed  to  the 
mains.  The  only  exception  which  occurs  to  me  at  the  moment 
is  the  town  of  Montrose,  in  Scotland,  where  the  inhabitants 
still  use  an  unfiltered  water-supply  from  the  river.  But 
while  the  source  of  the  water-supply  itself  may  be  pure, 
there  is  always  the  danger  in  an  epidemic  of  cholera  of  one  or 
other  of  the  mains  being  contaminated,  and  the  greatest  care 
must  be  taken  to  avoid  contamination  of  ground  either 
directly  or  through  a  defective  drainage-system.  In  moist 
soil  the  vibrio  of  cholera  is  capable  of  preserving  its  virulence 
for  a  long  time.  The  condition  of  the  source  and  distribution 
of  the  food-supply  must  be  most  carefully  enquired  into,  as 
any  contamination  of  milk  or  other  food  may  do  much  to 
spread  the  disease.  The  methods  of  dealing  with  the  infected 
area  and  infected  houses  should  be  similar  to  those  adopted 
in  the  case  of  plague  (q.  v.),  save  that  there  is  no  need  to 
inaugurate  a  campaign  against  rats. 

The  infected  area  should  be  visited  constantly  by  medical 
men,  who,  besides  looking  for  suspicious  cases,  ought  to  en- 
deavour to  infuse  a  spirit  of  cheerfulness  and  hope  among  the 
inhabitants,  and  drive  out  that  fear  which  is,  in  cholera,  such 
a  powerfully  predisposing  cause  of  the  disease.  The  people 
should  be  warned  against  the  drinking  of  unboiled  water. 
Filters  of  all  kinds  should  be  discouraged,  as  the  only  ones 
which  are  at  all  effective  are  those  of  the  Pasteur-Chamber- 
land  type,  and  the  ordinary  charcoal  filters  are  not  onh^  no 
protection,  but  a  positive  source  of  danger. 

The  question  as  to  how  far  people  coming  from  infected 
districts  should  be  limited  in  their  movements  in  non-infected 
areas  is  always  a  matter  of  discussion.     In  continental  countries- 


96  Chayter  V. 

ships  coming  from  an  infected  country  are  strictly  quar- 
antined, and  passengers  are  detained  at  frontier  towns, 
roughly  disinfected,  and  herded  in  ridiculous  discomfort  for 
some  days,  in  the  hope  of  checking  the  spread  of  cholera  by 
these  means.  Such  rigorous  quarantine  regulations  disorder 
the  trade  of  the  infected  country  and  lead  to  attempts  being 
made  to  conceal  the  existence  of  cholera  cases.  The  habit  in 
Great  Britain  has  been  to  examine  all  ships  coming  from  in- 
fected ports,  to  isolate  any  persons  who  appear  to  be  ill,  and 
supervise  the  goings  and  comings  of  the  other  passengers  until 
such  time  as  there  is  no  further  risk  of  their  developing 
cholera.  The  ships  are  thoroughly  disinfected  and  cleaned 
before  another  crew  is  allowed  on  board.  By  means  of  these 
milder  regulations  business  is  not  disorganised,  and  there  is 
less  likelihood  of  cases  being  concealed.  The  importance  of 
not  having  cases  concealed  is  obvious,  and  it  is  better  for  a 
district  to  have  a  dozen  declared  cases  of  a  disease  in  its  midst 
than  one  unknown  or  concealed  case. 

Prophylactic  inoculations  of  graded  strength  have  been 
practised  by  HafEkme,  and  in  the  course  of  an  epidemic 
tending  to  grow  at  all  large  in  one  of  our  western  cities  this 
might  well  be  tried  as  one  of  the  means  of  protecting  those  at 
work  among  the  sick,  and  of  helping  to  limit  the  spread  of  the 
disease. 


(   'J7   ) 


Chapter  VI. 


RELAPSING   FEVER 

Synonyms. — Febris       recurreris ;       Febris       reeidiva; 
Bilious  remittent  fever;  Famine  fever. 

Fr.  :      Fievre  a  rechutes. 

Ger.  :      Riickfalls  fieber;  Hungertyphus. 

Definition.  —  An  acute  infectious  disease  charac- 
terised by  a  sudden  febrile  onset,  short  course  and  rapid 
subsidence,  followed  at  an  interval  of  from  1-7  days  by  a  re- 
lapse, which,  with  a  similar  intervening  period,  may  be  re- 
peated an  indefinite  number  of  times.  It  is  associated  with 
the  presence  in  the  blood  and  tissues  of  spirochsetse,  one  of 
which  was  discovered  by  Obermeier  in  1873,  and  another, 
usually  called  the  Sp.  Duttoni,  by  Ross  and  Milne,  in 
Uganda,  and  Dutton  and  Todd,  in  the  Congo,  quite 
independently  of  one  another.  Carter  described  a  spirochseta 
similar,  apparently,  to  the  Sp.  recurrentis  of  Obermeier  as  oc- 
curring in  the  "relapsing  fever"  met  with  in  India. 

Incubation  Period.  —  The  incubation  period  is  usually 
from  two  to  six  days,  but  may  be  prolonged  to  fourteen  days. 

Rash.  —  No  rash  is  described  as  typical  of  the  disease, 
but  a  roseolar  eruption  in  character  something  between  measles 
and  typhus  has  been  seen  in  rare  instances. 

Clinical  Types. — It  would  seem  that  the  type  of  relaps- 
ing fever  as  met  with  in  Europe  and  India  differs  in 
certain  particulars  from  that  met  with  in  Africa,  and  from 
this  fact  and  because  there  are  certain  notable  differences  in 


98  Chapter  VI. 

morphology  between  the  spirochseta  recurrentis  of  Obermeier 
and  Carter  and  the  spirochsEitaDuttoni,  one  is  justified  in  saying 
that  relapsing  fever  in  Africa  is  a  different  disease  from  that 
met  with  in  Europe  and  India,  although  both  types  are  due  to 
infection  by  a  spirochseta,  and  in  general  resemble  each  other 
Tery  closely.  The  experiments  of  Todd  and  Brei  support  this 
view,  as  they  show  that  immunisation  against  the  spirochseta 
of  the  Indian  form  of  relapsing  fever  does  not  protect  against 
the  Sp.  Duttoni. 

European  and  Indian  Type.  —  The  onset  is  sudden, 
heralded  by  chill,  rigors,  giddiness,  severe  headache,  nausea 
and  vomiting.  The  temperature  rises  at  once  into  high  regis- 
ters, 104°  and  105°  F.  being  quite  usual  readings,  and  it  may 
even  rise  to  107°  or  108°  F.  The  pulse  and  respiration  are 
notably  increased  in  rate,  but  the  respiration-rate  is  not  in- 
creased proportionately  to  the  pulse.  Delirium  may  be 
present  if  the  fever  is  high.  The  skin  is  dry  and  burning.  As 
compared  with  typhus,  the  prostration  is  not  marked,  and 
the  patient  may  walk  to  consult  a  doctor  even  in  the  second  or 
third  day  of  his  illness,  but  giddiness  is  a  very  striking 
symptom.  The  face  is  flushed  but  not  dusky  and  heavy-look- 
ing as  in  typhus.  The  tongue  is  moist,  covered  with  a  thick 
white  fur,  and  thirst  is  usually  extreme.  Appetite  is  very 
variable,  being  in  some  cases  entirely  lost,  and  in  others 
quite  unimpaired.  There  is  sometimes  considerable  pain  and 
tenderness  in  the  epigastrium,  and  the  spleen  is  always  en- 
larged, with  marked  tenderness  on  pressure  over  the  area  of 
splenic  dulness.  The  liver  also  is  most  usually  enlarged.  A 
Blight  icteric  tinting  of  the  conjunctivae  is  very  commonly 
present,  and  in  a  fair  proportion  of  cases  generalised  jaundice 
appears  about  the  third  day  of  the  fever.  In  such  cases  the 
urine  is  bile-stained,  but  the  stools  remain  dark  in  colour. 
The  fever  usually  remains  high  for  some  five  to  seven  days, 
showing  no  great  degree  of  oscillation ;  the  pulse  varies  with 
the  temperature,  and  may  be  very  rapid  indeed.  The  patient 
siiffers  much  from  headache  and  pains  in  the  back  and  limbs. 
Sleeplessness  is  almost  always  a  source  of  trouble,  and  the 
mind  usually  remains  clear  although  some  delirium  may  be 
present.     On  the  fifth,   sixth  or  seventh  day  the  fever  falls 


Relapsing     Fever.  99 

rapidly  by  crisis,  and  it  is  common  to  have,  just  before  the 
crisis,  a  rise  of  temperature  even  of  several  degrees,  while 
with  the  pre-critical  rise  violent  delirium  and  restlessness  may 
set  in  for  a  short  time.  The  fall  of  temperature  to  normal  or 
subnormal  registers  is  very  rapid — a  fall  of  8°  or  10°  F.  in  a 
few  hours  being  quite  common.  Murchison  records  in  one 
case  a  fall  of  13°  F.  in  six  hours,  and  in  another  a  fall  of 
14*4°  F.  in  twelve  hours.  The  crisis  is  usually  accompanied 
by  profuse  sweating,  and  sometimes  diarrhoea  and  epistaxis 
occur.  As  in  all  diseases  where  fever  terminates  by  crisis,  the 
sudden  fall  of  temperature  may  be  attended  by  dangerous  and 
even  fatal  collapse.  In  aged  and  feeble  patients  death  may 
occur  with  coma  before  the  end  of  the  first  paroxysm.  After 
the  first  crisis,  there  is  an  interval  of  apyrexia  which  lasts  for 
a  variable  time,  usually  for  five  or  seven  days,  but  intervals  as 
short  as  two  and  as  long  as  twenty-five  days  have  been  re- 
corded. During  the  apyretic  interval  the  patient  feels  well 
and  will,  perhaps,  be  with  difiiculty  restrained  in  Hospital, 
but  at  its  termination  he  is  suddenly  seized  with  the  same 
acute  symptoms  and  rise  in  temperature  as  ushered  in  his 
first  paroxysm.  This  first  relapse  may  last  as  long  as  the 
first  paroxysm,  but  is  usually  somewhat  shorter  and  may  last 
only  for  a  couple  of  days.  It  terminates  by  crisis,  as  did  the 
first  paroxysm,  and  this  may  end  the  attack.  But  in  some 
patients,  after  a  short  second  period  of  apyrexia  a  second 
relapse  occurs,  which  is  usually  milder  than  the  preceding, 
and  of  short  duration,  rarely  exceeding  three  days  After  its 
termination  the  attack  is  in  most  cases  finished,  but  more 
rarely  a  third,  fourth  or  even  fifth  relapse  may  occur.  After 
the  termination  of  the  last  relapse,  convalescence  is  often  a 
little  tedious,  and  the  patient  does  not  recuperate  with  the 
same  rapidity  as  after  typhus,  and  his  recovery  may  be  de- 
layed by  certain  troublesome  complications  and  sequelae. 
Throughout  the  attack,  save  at  the  time  of  the  crisis,  the 
bowels  tend  to  be  constipated. 

The  tj^pical  course  of  the  disease  is  not  always 
followed.  In  some  cases  there  is  no  relapse  after  the  first 
crisis,  while  in  others  there  is  no  definite  crisis  at  the  end  of 
the  first  paroxysm,  but  the  temperature  after  an  incomplete 

B    2 


100  Chapter  VI . 

fall  tends  to  rise  again  and  tlie  patient  drifts  into  a  typhoid 
state  in  which  he  may  die  from  asthenia,  sudden  cardiac 
failure,  or  suppression  of  urine  with  violent  symptoms  of 
uriemia.  vSuch  "  typhoid  "  cases  are  commonly  deeply  jaun- 
diced and  vomit  dark  bilious  material,  while  they  sometimes 
have  numerous  haemorrhages  into  the  skin  and  from  mucous 
surfaces,  presenting  a  "  liaBmorrhagic"  form  of  the  disease. 

African  Type. — The  ''  African  "  type  of  relapsing  fever 
diifers  in  many  respects  from  the  "Indo-European"  type, 
although  in  general  the  manifestations  are  very  similar.  There 
is  the  same  sudden  onset  and  abrupt  termination  of  the  initial 
paroxysm  and  the  same  tendency  to  relapse  after  irregular 
periods  of  apyrexia.  The  initial  paroxysm,  however,  is 
shorter  than  in  the  European  type,  and  terminates  in  most 
cases  about  the  end  of  the  third  day.  The  intervals  of 
apyrexia  are  of  very  irregular  duration,  varying  from  one  day 
to  nearly  three  weeks,  and  the  number  of  relapses  is  usually 
greater  than  in  the  "European"  type,  five  or  six  relapses 
being  the  rule,  and  as  many  as  eleven  having  been  observed. 
The  fever  is  shorter  in  the  relapses  than  in  the  initial 
paroxysm,  but  rises  quite  as  high.  The  intervals  of  apyrexia 
become  longer  as  the  attack  proceeds.  Another  point  of  dif- 
ference between  the  types  is  that  in  the  "African"  form 
diarrhoea  and  dysenteric  manifestations  are  fairly  common. 

Diagnosis.  —  The  diseases  most  likely  to  be  confused 
with  relapsing  fever  are  malaria,  enteric  fever,  typhus  fever 
and  influenza,  but,  although  at  the  beginning  of  the  attack 
there  is  little  to  distinguish  it  from  typhus  or  enteric  fever 
with  a  sudden  and  severe  onset,  the  course  of  the  disease, 
showing  as  it  does  a  definite  "relapsing"  character,  the  first 
relapse  occurring  about  fourteen  days  from  the  onset  of  symp- 
toms, makes  differentiation  comparatively  easy.  The  dura- 
tion of  the  paroxysms  distinguishes  it  from  malaria.  It  is 
during  the  first  paroxysm  that  differentiation  from  other  fevers 
may  be  difficult,  but  the  clear,  vigilant  look  in  the  eyes  and 
the  absence  of  a  dusky  flush  on  the  face  will  help  to  differen- 
tiate it  from  typhus,  and  the  early  enlargement  of  the 
spleen   is  unlike    that  seen  in    enteric    fever.       For    accurate 


Relapsing     Fever.  101 

diagnosis,  however,  we  must  depend  on  the  micioscoi)ic!iJ  ex- 
amination of  the  blood  and  the  detection  of  spirochsetse.  The 
spirochsetse  stain  well  with  ordinary  basic  anilin  dyes,  ;ind 
gentian  violet  is  a  convenient  stain  to  use  for  the  purpose 
after  drying  the  film  made  from  the  blood  and  fixing  it  with 
absolute  alcohol.  Jenner's  and  Leishman's  stains  give  very 
pretty  results.  The  sp.  recurrentis  of  Obermeier  is  a  delicate 
spiral  thread  from  T  />l  — 9  /i  long,  while  the  sp.  Duttoni  of 
the  "African  type"  measures  some  16  fx  in  length,  or  about 
twice  as  long  as  the  sp.  recurrentis.  The  sp.  Duttoni  tends  to 
form  loops  and  coils  of  a  "  figure-of-eight  "  sbape.  In  the 
"  European  "  type  of  the  disease,  the  spirochgetae  are  found  in 
great  numbers  in  the  peripheral  blood  stream  during  a 
paroxysm,  but  in  the  "  African  "  type  they  are  apt  to  be 
scanty  and  difficult  to  find  except  after  repeated  examinations. 
It  would  seem  to  be  quite  possible  that  in  various  parts  of  tlie 
world  *'  relapsing  fever "  may  occur  which  is  caused  by 
spirochsetse  differing  in  some  degree  from  those  described,  but 
on  this  point  further  evidence  is  needed  before  any  definite 
statement  as  to  their  occurrence  can  be  made. 

Complications.  —  These  are  not  numerous,  and  the  most 
serious,  lobar  pneumonia,  is  one  of  the  rarest.  Pneumonia 
has  been  fairly  frequent  in  certain  European  epidemics,  but 
quite  uncommon  in  Great  Britain.  Sometimes  the  pneumonic 
consolidation  breaks  down  and  results  in  gangrene  of  the 
lung.  Bronchitis  is  very  common,  but  is  seldom  more  than  a 
very  slight  catarrh  of  the  larger  bronchi.  Diarrhoea  and  a 
form  of  dysentery  have  been  troublesome  complications  during 
certain  epidemics,  and  rupture  of  the  spleen  and  the  breaJdng- 
down  of  a  splenic  einbolus  have  occasionally  been  noted  as  a 
cause  of  death,  the  former  resulting  in  Aaolent  hfemorrhag'^, 
and  the  latter  in  general  peritonitis.  Parotitis  and  inguinal 
bubo  sometimes  occur,  and  have  been,  in  some  epidemics,  a 
most  unfavourable  sign,  but  in  Great  Britain  they  seem  to 
have  occurred  most  frequently  in  cases  which  ultimately  re- 
covered. Pregnant  women  near  always  abort,  but  the  abor- 
tion is  not  uncommonly  delayed  till  the  relapse.  When  abor- 
tion does  occur  it  is  frequently  fatal,  and  the  child  is  still-born 
or  dies  within  a  few  hours. 


102  Chapter  VI. 

SequelcB. — Multi'ple  7ieuritu,  synovitis,  associated  with 
severe  articular  pain  and  sometimes  with  effusion  into 
the  knees  or  anlcles,  nephritis  and  a  form  of  ophthalmia 
have  all  been  observed  as  sequelse  of  relapsing  fever.  The 
ophthalmia  occurs  first  as  an  affection  only  of  the  retina  and 
choroid,  but  involves  secondarily  the  more  supercificial  struc- 
tures, and  is  then  associated  with  severe  pain.  Only  one  eye 
is  commonly  involved,  but  recovery  is  always  tedious,  while 
in  a  certain  proportion  of  cases  vision  is  lost. 

Treatment.  —  No  drug  treatment  has  yet  been  intro- 
duced which  has  been  successful  in  cutting  short  the  course  of 
the  disease,  and  treatment,  in  the  absence  of  serumtherapy, 
must  be  palliative  and  symptomatic.  Where  the  bowels  tend 
to  be  constipated,  a  mild  aperient  should  be  given  throughout 
the  attack.  The  patient  may  be  made  more  comfortable  by 
cold  or  tepid  sponging,  and  by  the  application  of  cold  to  the 
head,  either  by  cloths  dipped  in  iced  water  or  by  means  of  a 
Leiter's  coil.  When  epigastric  or  hypochondriac  pain  is  severe 
the  giving  of  an  emetic,  followed  by  the  application  of  tepid 
compresses  to  the  abdomen  may  afford  relief.  It  is  wise  to 
give  a  simple  diuretic  or  diaphoretic  mixture  consisting  of 
Liq.  Ammon.  Acet.  ^i,  Potass.  Acet,  grs.  x,  and  Spr.  Aetheris 
Nitrosi  TT^xv,  at  three-hourly  intervals  throughout  the  attack, 
as  one  of  the  dangers  of  the  disease  is  scanty  urinary  output 
with  symptoms  of  uraemia.  Should  ursemia  be  seriously 
threatening,  it  is  well  to  give  an  intracellular  injection  of  hot 
saline  solution,  and  bleeding  may  be  resorted  to  in  addition. 
Opium  may  be  of  service  in  the  relief  of  pain  and  sleepless- 
ness, either  alone  in  the  form  of  Battley's  solution  or  in  com- 
bination with  a  small  dose  of  chloral  hydrate,  while  powdered 
opium  either  alone  or  in  the  form  of  Dover's  Powder  may  be 
helpful  when  there  is  much  diarrhcea,  or  when  there  is  a 
tendency  for  the  stools  to  be  dysenteric.  Alcohol  may  be  used 
with  advantage  at  the  time  of  crisis,  in  small,  frequently 
repeated  doses. 

Diet. —  The  diet  should  be  fluid,  consisting  oi  milk, 
barley  water  and  beef -tea  or  some  clear  soup,  during  the 
periods  of  fever,  and  after  the  fever  lias  declined,  a  semi-solid 


Relapsing     Fever.  103 

diet  may  be  given  at  once,  if  there  is  no  diarrlu/ja  or  neph- 
ritis present.  During  convah;scence  a  mixed  diet  may  be 
rapidly  resumed  according  to  the  patient's  wishes  and 
capacity. 

Epidemiology. —  li-elapsing  fever  has  not  occurred 
in  Great  Britain  in  any  considerable  epidemic  since 
1870.  One  death  occurred  in  Glasgow  in  1879,  and  three  in 
Ireland  in  1890,  but  since  then  no  cases  have  been  observed 
in  the  British  Isles.  It  is  still  met  with,  however,  in  Eastern 
Europe  and  in  Asia,  and  the  "African"  type  is  common  in 
the  region  of  the  Great  Lakes  and  on  the  Congo.  Relapsing 
fever  is  usually  associated  with  unusual  poverty  and  squalor, 
with  consequent  enfeeblement  of  health,  so  much  so  that  in 
many  of  the  epidemics  which  appeared  in  the  large  towns  of 
Great  Britain,  the  vast  majority  of  the  cases  were  destitute 
Irish  people  who  had  just  left  their  native  country,  while  the 
English  and  Scottish  inhabitants  were  attacked  in  small  num- 
bers. But  it  is  quite  conceivable  that  with  the  practically  un- 
restricted alien  immigration  which  is  usual  in  this  country, 
the  disease  may  once  more  gain  entry  to  British  towns,  and 
the  great  mass  of  filthy  and  destitute  people,  and  the  dirty 
and  insanitary  condition  of  certain  portions  of  our  towns 
would  form  a  very  suitable  nidus  for  a  severe  epidemic. 

Death  Rate. — This  is  low  as  compared  ■'vith  most  of 
the  infectious  fevers,  from  4  to  6  per  cent,  being  usually  given 
as  the  average  mortality  in  an  epidemic. 

Method  of  Infection. — There  seems  to  be  little  reason 
to  doubt  that  the  "European"  type  of  the  disease  is 
conveyed  from  person  to  person  by  vermin,  particularly  by 
bed-bugs  and  body-lice,  and  it  seems  probable  that  the 
apparent  spread  of  the  disease  by  clothing  and  bedding  has 
really  been  due  to  the  fact  that  such  clothing  or  bedding  has 
been  the  habitat  of  some  of  these  parasites.  In  the  "African" 
type,  the  infection  is  spread  by  a  form  of  tick,  the  ornitho- 
dorus  mouhata. 

Home  Prophylaxis. — The  strictest  cleanliness  of  house 
and    person    must    be    observed,   in  view    of    the  possibilitv 


104  Chapter  VI. 

of  the  transmission  of  the  disease  by  vermin.  Those  in  con- 
tact with  the  patient  should  avoid  contamination  by  the  dis- 
charges as  far  as  possible,  especially  if  the  case  be  complicated 
with  pneumonia  or  be  of  the  hsemorrhagic  type.  Abrasions 
of  the  skin  should  be  carefully  cleaned  and  sealed  up  with 
collodion  or  "  new  skin."  Patients  in  the  poorer  localities  of 
an  infected  district  should  not  be  kept  at  home,  as  the  dilapi- 
dated plaster  and  wood-work  in  such  districts  harbour  vermin 
in  large  numbers  and  proper  isolation  is  impossible.  In 
Africa,  the  traveller  should  avoid  as  far  as  possible  old 
camping-grounds  and  native  villages,  and  should  use  a  mos- 
quito-net and  a  bed  elevated  some  distance  above  the 
ground.  A  night-light  is  also  an  advantage,  as  the  ornitho- 
donis  mouhata  makes  its  attacks  usually  in  the  darkness  and 
may  be  deterred  by  light. 

Public  Health  Administration. — As  in  cholera  and  plague, 
the  duty  of  the  Health  Office  is  to  see  to  the  strict 
isolation  of  all  affected  patients,  to  remove  to  hospital  all 
those  attacked  who  are  living  in  squalid  and  crowded  districts, 
to  thoroughly  cleanse  and  disinfect  all  houses  where  cases  have 
occurred,  and  all  articles  which  have  been  in  contact  with  a 
patient. 

Strict  supervision  of  contacts  and  suspected  cases  must  be 
exercised,  and  opportunity  afforded  to  practitioners  for  bac- 
teriological diagnosis,  either  by  the  examination  of.  blood-films 
alone,  or  by  animal  inoculations. 


(    105   ) 


Chapteii   VTI. 


MALARIA. 

Synonyms. —  Ague,  Intermittent  Fever,  Marsh  Fever. 

Fr.  :      Malaria,    Fievre    intermittente,    Fievre 
Palustre, 

Gev.  :      Malaria,  Wechsel  Fieber,  Sumpffieber. 

Definition. —  An  acute  disease  characterised  by  attacks 
of  fever,  usually  of  a  periodic  character,  separated 
by  variable  intervals  of  more  or  less  complete  apyrexia,  due 
to  the  presence  in  the  blood  and  viscera  of  a  specific  sporozoon 
discovered  by  Laveran  in  1880.  The  host  of  this  sporozoon  is 
the  mosquito,  by  which  it  is  conveyed  to  man. 

Incubation  Period. — The  incubation  period  for  malaria 
seems  to  vary  from  about  twenty-four  hours  to  several 
weeks.  Instances  have  been  recorded  of  patients  developing 
the  disease  within  twenty-four  hours  of  their  arrival  in  a 
malarious  district,  and,  on  the  other  hand,  I  recollect  a 
patient,  who  had  never  previously  suffered  from  malaria,  but 
who,  after  staying  a  week  in  New  Orleans  during  September, 
sailing  from  there  in  a  tramp  steamer  to  the  Netherlands  and 
Germany,  and  afterwards  coming  by  easy  stages  to  Liverpool 
and  Glasgow,  developed  malaria  after  he  had  been  ashore  and 
exposed  to  the  chills  of  a  Scottish  December  for  a  fortnight. 
His  attack  was  a  benign  tertian. 

Rash. — No  typical  eruption  has  been  observed  in  malaria. 

Clinical  Type. —  The  three  main  types  of  malarial  fev^r 
are  the  Tertian,  the  Quartan,  and  the  Aestivo-Autumnal 
or  Malignant  Malaria. 

1.  Tertian  MaJaria  is  so  called  because  the  febrile 
paroxysm  occurs  on  every  alternate  day.     (See  Chart  1.) 


106  Chapter  VII. 

The  febrile  paroxysm  is  clinically  divided  into  three 
stages,  the  ''  cold  stage,"  the  "  hot  stage  "  and  the  "  sweating 
stage."  At  or  about  the  same  time  in  each  day  on  which  a 
paroxysm  occurs,  the  attack  is  ushered  in  by  the  development 
of  the  cold  stage,  in  which  the  patient  is  seized  with  a  feeling 
of  chill  and  shivering,  and  almost  always  has  a  marked  rigor, 
which  is  sometimes  so  severe  as  to  make  standing  upright  im- 
possible without  support  and  to  shake  the  bed  or  couch  on 
which  he  lies.  The  "  cold  stage  "  is  sometimes  preceded  by 
some  hours  of  general  discomfort  and  lassitude,  with  subjec- 
tive sensations  of  nausea,  slight  headache,  pain  in  the  bones 
and  a  feeling  of  cold  water  trickling  down  the  spine.  During 
the  stage  of  premonitory  symptoms  the  temperature  often 
rises  slightly.  In  some  instances  the  premonitory  symptoms 
pass  off  without  being  followed  by  a  properly  developed 
paroxysm  of  the  disease,  but  usually  after  a  few  hours  they 
are  followed  by  the  chill  and  rigor  which  characterise  the 
onset  of  the  "  cold  stage."  The  feeling  of  chill  is  purely  sub- 
jective, as  although  the  hands  and  feet  are  cold  to  the  touch, 
the  temperature  in  the  axilla  and  rectum  is  seen  to  rise  during 
the  whole  period  of  chill  and  rigor.  At  the  same  time  the 
patient  suffers  acutely  from  headache  and  nausea  and  may 
vomit  severely.  His  face  is  pinched  and  pallid,  with  some 
cyanosis  of  the  lips  and  ears,  and  he  heaps  coverings  on  him- 
self in  the  endeavour  to  get  warm.  In  young  children  the 
rigor  is  sometimes  accompanied  by  convulsive  seizures. 

After  the  "cold  stage '^  has  lasted  for  about  an  hour,  the 
Jtot  stage  begins,  in  which  the  patient  begins  to  feel  warmer, 
and  the  feeling  of  warmth  rapidly  increases,  alternating  some- 
times with  chilliness  for  a  short  time,  until  within  an  hour  he 
suffers  from  burning  heat  and  discards  the  coverings  which  he 
has  heaped  on  himself  during  the  "cold  stage."  During 
this  period  the  temperature  rises  still  further  until  it  may 
reach  very  high  levels  indeed,  temperatures  of  106°  F.  being 
frequently  recorded.  The  face  is  flushed,  the  skin  dry  and 
burning,  headache  is  severe,  and  vomiting  may  be  distressing. 
The  pulse  is  full  and  bounding  and  respirations  are  rapid. 

After  one  or  two  hours  of  acute  discomfort,  the  final  or 
sweating  stage  of  the  paroxysm  is    reached.        The    patient 


Malaria.  107 

breaks  into  a  profuse  perspiration,  tlie  feeling  of  heat  passes 
away,  the  fever  declines,  headache  and  nausea  disappear,  and 
the  pulse  and  respiration  become  quiet.  The  sweating  lasts 
one  or  two  hours,  and  when  it  ceases  the  patient  feels  tranquil 
and  languid,  and  in  a  few  hours  he  may  feel  well  enough  to 
go  about  his  work  again.  The  whole  paroxysm  thus  lasts  for 
about  six  hours,  and  in  the  tertian  type  is  not  repeated  on 
the  following  day,  but  is  repeated  on  the  day  after,  in  all  its 
stages,  at  or  about  the  same  hour  as  it  occurred  two  days 
earlier. 

The  spleen  enlarges  during  the  paroxysm  and  recedes  at 
first  during  the  apyretic  interval,  but  after  several  paroxysms 
the  spleen  remains  enlarged  during  the  interval,  still  tending 
to  increase  somewhat  during  the  paroxysm. 

The  urine  is  passed  frequently  during  the  cold  stage,  and 
at  this  period  is  actually  increased  in  quantity  above  the  nor- 
mal. The  excretion  of  urea  is  also  increased  during  the 
paroxysm,  and  for  some  hours  afterwards. 

It  is  possible  to  h^'ve  two  attacks  of  tertian 
ague  running  at  the  same  time,  so  that  each  daj  may  be 
occupied  by  a  paroxysm,  and  a  quotidian  character  given  to 
the  fever.  The  clinical  manifestations  often  bear  evidence  of 
this  apart  from  microscopical  examination  of  the  blood, 
inasmuch  as  the  attacks  on  two  consecutive  days  may  vary 
greatly  in  severity  and  may  reach  their  height  at  quite 
different  times.  (See  Chart  2.)  This  is  not  always  the  case. 
Two  tertian  infections  may  mature  at  about  the  same  time 
each  day,  and  present  a  picture  of  a  quotidian  ague  having 
its  maximum  swing  about  the  same  hour.  But  the  infecting 
organism  presents  no  difference  from  that  found  in  an  infec- 
tion with  regular  tertian  manifestations,  so  that  even  when 
the  quotidian  paroxysms  appear  at  or  about  the  same  hour 
each  day,  we  are  bound  to  consider  the  attack  to  be  a  double 
tertian,  due  to  two  infections  by  the  parasite  of  tertian 
malaria,  which  mature  on   different  days. 

2.  Quartan  Malaria :  In  the  quartan  type  of  the  disease 
the  paroxysms  are  separated  by  an  interval  of  two  days  of 
apyrexia  (see  Chart  3),  but  are  made  up  of  the  same  three 


108  Chapter  VII. 

stages  of  cold,  heat  and  sweating  as  in  the  tertian  type  of  the 
disease,  and  have  a  similar  duration.  A  double  or  triple  in- 
fection by  the  quartan  parasite  may  take  place,  so  that  two 
consecutive  days  may  show  a  paroxysm,  followed  by  a  day  of 
apyrexia,  or  the  paroxysms  may  occur  daily. 

3.  Aestivo- Autumnal  or  Malignant  Malaria. — In  this 
type  of  the  disease  the  paroxysms  are  not  quite  the  same  as 
in  the  benign  tertian  and  quartan  fevers.  In  certain  cases, 
they  follow  a  regular  type,  and  are  separated  from  each  other 
by  a  definite  period  of  apj-rexia.  (See  Chart  4.)  In  such 
cases  the  rigor  may  be  much  less  severe  than  in  the  benign 
types,  but  the  hot  stage  lasts  longer,  sometimes  occupying 
twenty-four  hours.  It  is  not  uncommon  in  this  type  of  infec- 
tion to  have  a  fall  of  some  degrees  of  temperature,  or  pseudo- 
crisis,  some  hours  before  the  real  termination  of  the  paroxysm. 
In  other  cases  of  malignant  infection  the  paroxysms  are  well 
defined,  of  short  duration  and  occur  dail}^  and  tliere  seems 
reason  to  believe  that  many  of  the  quotidian  types  of  ague, 
apart  from  the  double  infection  by  the  tertian  parasite,  may 
be  due  to  a  separate  organism,  which  has  not  yet  been  fully 
studied  and  described.  Another  type  due  to  a  malignant  in- 
fection is  the  remittent  (see  Chart  5),  where  no  period  of 
apjTexia  separates  ihe  paroxysms,  but  where  the  termination 
of  one  is  not  complete  before  another  begins.  In  such  cases 
the  stages  of  the  paroxysms  are  usually  not  well  marked ; 
rigor  may  be  replaced  by  a  sensation  of  chill,  and  sweating* 
may  be  no  marked  feature  during  the  decline  of  the  fever.  In 
other  cases  the  febrile  movement  may  be  very  slight  and 
quite  irregular.  Part  of  the  irregularity  in  the  manifesta- 
tions is,  doubtless,  frequently  due  to  previous  dosing  with 
quinine,  as  it  is  quite  uncommon  to  find  Europeans  who  have 
been  in  a  malarious  district  for  any  length  of  time  who  have 
not  used  quinine  for  prophylactic  purposes.  At  the  same 
time,  apart  from  the  administration  of  quinine,  the  mani- 
festations of  a  malignant  infection,  especially  if  the  infection 
has  been  repeated  several  times,  tends  to  be  accompanied  by 
febrile  movements  which  may  be  slight  and  atypical,  although 
the  other  constitutional  disturbances  may  be  grave.  (See 
Chart  6.)       A  malignant  infection  may  be  accompanied  by 


Malaria.  109 

jaundice,  with  much  vomiting  (the  hilious  remittent  type  of 
tlie  disease),  and  in  some  cases  may  be  speedily  followed  by 
cerebral  symptoms,  siicli  as  stupor,  convulsions  and  coma.  In 
such  attacks  the  temperature  may  rise  to  very  hi^li  registers, 
iind  death  may  occur  with  a  hyperpyrexia  of  109°  or  110°  F. 
Yet  another  form  of  the  disease  may  be  developed  by  a 
malignant  infection — the  ahjide  form,  characterised  by  col- 
Lvpse,  coldness  of  the  surface  of  the  body  and  a  tendency  \a) 
syncopal  attacks.  A'^omiting  may  be  present,  or  profuse  watery 
diarrhoea  with  collapse  closely  simulating  cholera,  or  haemorr- 
hage from  the  bowel  or  stomacli.  In  other  cases,  particularly 
in  such  as  show  signs  of  cachexia,  the  sweating  stage  may  be 
dissociated  with  a  proneness  to  sudden  cardiac  failure,  which 
may  be  induced  by  an  injudicious  movement  on  the  patient's 
part.  It  is  cases  of  this  kind  that  shoAv  how  important  it  is  that 
an  early  and  accurate  diagnosis  of  the  particular  infecting 
organism  should  be  made. 

Mixed  Infections. —  In  certain  cases  of  malaria  more  than 
one  kind  of  infecting  organism  may  be  present,  and  in  these 
cases  the  disease  may  show  most  irregular  manifestations,  due 
to  a  blending  of  the  benign  types  of  tertian  and  quartan 
malaria,  or  to  a  mixture  of  the  benign  and  the  malignant  in- 
fections. Such  cases  can  only  be  elucidated  by  the  careful 
and  systematic  examination  of  the  blood,  and  the  recognition 
of  the  various  infecting  organisms. 

Mild  types. —  In  many  instances,  a  person  living  in  a 
malarious  district  suffers  from  headache,  nausea  and  general 
malaise  for  some  hours  without  the  occurrence  of  rigor,  heat 
or  sweating,  and  this  attack  may  be  repeated,  with  intermis- 
sions of  varying  length,  several  times,  and  in  some  such  cases 
a  typical  attack  of  malaria  develops  out  of  the  attack.  In 
others,  however,  the  symptoms  are  apparently  not  prodromal 
to  an  attack  of  true  malaria,  but  constitute  in  themselves  an 
abortive  attack  of  the  disease,  ultimately  disappearing  without 
the  development  of  a  febrile  paroxysm. 

Diagnosis.  —  The  only  accurate  means  of  diagnosis  in 
malaria  is  the  microscopical  examination  of  the  blood  and  the 
detection  of  one  or  other  of  the  forms  of  the  malarial  parasite. 


110  ,  Chafer  VII. 

The  three  parasites  usually  described  are  the  tertian,  quartan, 
and  vialignant. 

For  those  who  have  not  had  great  experience  in 
malaria  it  is  wise  to  examine  dried  films  of  blood  which  have 
been  stained  by  the  Romanowsky  method  or  one  of  its  modi- 
fications. Personally,  I  prefer  to  use  Jenner's  or  Leishman's 
stains  as  being  both  simple  to  manipulate  and  effective  in 
action.  When  stained  by  these  methods  the  red  blood  cor- 
puscles appear  brownish-red,  nuclei  appear  blue  and  the 
parasite  shows  a  blue  protoplasm  with  red  chromatin. 

The  benign  tertian  parasite  when  stained  appears  in  :i 
red  blood  corpuscle  as  a  small  blue  ring,  with  one  part  of  its 
circumference  slightly  thicker  than  the  other,  containing  a 
bright  red  spot  of  chromatin.  As  it  grows  it  is  seen  as  a  more 
or  less  regularly-stained  blue  mass  of  protoplasm,  containing 
fine  granules  of  pigment  which  it  has  acquired  from  the  red 
blood  corpuscles.  The  red  blood  corpuscle  enlarges  with  the 
growth  of  the  parasite,  assuming  the  appearance  of  a  large 
megalocyte,  and  is  occupied  almost  entirely  by  the  parasite 
when  it  has  reached  maturity.  The  parasite  matures  both  as 
a  sexual  and  an  asexual  form.  The  sexual  form  is  practically 
undistinguishable  from  a  full  grown  asexual  parasite  before 
sporulation  has  taken  place,  i.e.,  it  appears  as  a  large  more  or 
less  homogeneous  protoplasmic  mass  stained  blue,  containing 
numerous  pigment-granules  and  irregularly  distributed 
chromatin.  In  the  asexual  form,  which  is  proceeding  to  spore- 
formation,  the  pigment  collects  itself,  as  the  parasite  grows, 
into  two  small  masses  at  the  centre,  while  the  chromatin 
gathers  at  the  periphery.  Radial  segmentation  of  the  organism 
occurs,  and  the  result  is  a  grouping  of  some  fifteen  to  twenty- 
six  oval  spores,  each  containing  a  red  dot  of  chromatin,  like  a 
bunch  of  grapes  round  one  or  two  central  masses  of  coarse 
brown  pigment.  The  remains  of  the  red  blood  corpuscle,  at 
least  from  the  time  that  the  organism  is  half -grown,  show,  in 
deeply  stained  specimens,  an  appearance  of  granules  to  w^hich 
has  been  given  the  name  of  "  Schxiffner's  dots."  Imme- 
diately before  the  occurrence  of  a  febrile  paroxysm,  the  cor- 
puscle ruptures  and  the  spores  are  set  free  in  the  blood-stream. 


Malaria.  Ill 

The  spores  may  invade  other  red  blood  corpuscles  and  be  the 
starting  point  of  another  cycle.  The  sexual  forms,  or 
"  gametocytes,"  do  not  develop  fully  m  the  human  blood,  but 
when  removed  from  the  body  certain  of  them  remain  as 
large  roughly  spherical  bodies,  with  a  faint  appearance  of  seg- 
mentation in  the  j^rotoplasm.  These  are  the  female  forms  or 
"  macrogametes."  Others  produce  pseudopodia,  which  con- 
stitute the  male  element  of  the  parasite,  and  become  detached, 
appearing  as  elongated  motile  bodies,  the  "  microgametes," 
which  effect  conjunction  with  the  female  macrogamete. 
Pseudopodia  are  never  seen  in  the  circulating  blood,  but  the 
formation  of  flagellate  forms  are  frequently  seen  during  the 
examination  of  fresh  specimens  of  malarious  blood  under  the 
microscope,  especially  when  a  hot  stage  is  used.  I  have  seen 
one  such  flagellate  organism  under  a  high  power,  surrounded 
by  three  large  polymorpho-neuclear  leukocytes  who  ulti- 
mately consumed  it,  and  went  off  with  pigment  in  their 
interiors. 

The  quartan  iiarasite  is  much  smaller  than  the  tertian, 
and  does  not  grow  beyond  the  size  of  a  red  blood-corpuscle.  In 
its  early  or  "  ring-form  "  stage  it  is  quite  indistinguishable 
from  the  tertian  parasite,  but  the  fact  that  it  does  not  cause 
enlargement  of  the  red  blood  corpuscle  as  it  reaches  full 
growth,  and  that  the  protoplasm  of  the  red  blood-corpuscle 
does  not  show  "  Schiiffner's  dots"  ar©  notable  points  of  differ- 
ence. The  quartan  sporulating  form  is  much  smaller  than 
the  tertian,  and  the  segments,  some  eight  or  ten  in  number, 
are  arranged  in  characteristically  regular,  "  daisy-like " 
formation  round  a  central  dense  mass  of  very  dark  pigment. 
Microgametes  and  macrogametes  are  formed  as  in  the  tertiao 
parasite. 

The  "  Tnalignant  parasite  "  is  still  smaller  than  the 
quartan,  and,  indeed,  to  those  unskilled  in  the  examination  of 
the  blood  for  the  malarial  parasite  it  may,  even  in  stained 
specimens,  readily  escape  notice  in  its  early  or  "ring"  form. 
The  blue  ring  is  often  of  hair-like  thinness,  even  under  an  oil- 
immersion  lens,  and  the  chromatin-dot  is  very  small  indeed. 
This  makes  the  detection  of  the  parasite  in  many  cases  a 
matter  of  extreme  difficulty,  as  it  is  very  uncommon  to  find 


112  Chapter  VII. 

sporulation  forms  of  the  "  malignant  "  parasite  in  the  peri- 
plieral  blood-stream,  although  it  has  been  observed  in  certain 
cases,  and  one  is  usually  dependent  on  the  detection  of  the 
"  ring-form  "  for  the  formation  of  a  diagnosis.  The  sexual 
form  "of  the  parasite  is,  however,  very  characteristic.  It 
appears  as  a  crescent-shaped  body,  to  the  concavity  of  which 
is  usually  seen  adhering  a  fragment  of  a  red  blood-corpuscle. 
The  crescent-body  stains  a  pale  violet  and  shows  in  its  centre 
an  agglomeration  of  fine  granules  of  pigment.  This  form  is 
rarely  visible  during  a  febrile  movement.  The  sporulating 
forms  are  very  small,  and  show  an  irregular  heap  of  from  six 
to  twelve  spores.  The  blood-corpuscle  which  has  been  invaded 
l)y  the  malignant  parasite  frequently  shrinks,  becomes  darker 
in  colour  than  the  normal,  and  tends  to  show  a  crenated  margin. 

While  this  description  applies  generally  to  all  the  forms 
of  malignant  parasite,  it  is  only  right  to  say  that  Manson, 
following  Italian  observers,  recognises  three  malignant  para- 
sites, viz.  : — (1)  the  ordinarily-described  parasite  of  malignant 
tertian  ague,  Laverania  malarioe,  which  displays  a  fine  pig- 
ment; (2)  a  pigmented  quotidian  parasite,  Laverania  jjrcecox; 
and  (3)  an  unpigmented  quotidian  parasite,  Laverania 
iTmnaculata.  Of  the  two  pigmented  forms,  Laverania 
Tnalaricc  is  the  larger,  being  about  ^-f  the  size  of  a  red  blood- 
corpuscle,  while  Laverania  "prcecox  is  just  one  half  of  that 
■size.  In  both  of  these  parasites,  pigment  can  be  seen  scattered 
through  the  partly  matured  forms  and  collected  in  small 
irregular  masses  in  the  centre  of  the  sporulation  and  crescent 
forms . 

The  hloocl  in  malaria  presents  certain  characteristics 
apart  from  the  presence  of  the  parasite,  which  may  arouse  a 
suspicion  in  the  mind  of  the  physician  that  the  case  is  one  of 
ague.  Some  degree  of  ansemia  is  always  present,  and  in 
malignant  cases  the  red  corpuscles  tend  to  show  a  diminution 
in  size,  a  density  greater  than  normal,  and  a  crenation  of 
their  edges.  The  presence  of  pigment  in  the  leukocytes  or  free 
in  the  blood-stream  should  always  suggest  the  possibility  of 
an  otherwise  unexplained  pyrexia  being  of  malarial  origin  if 
ihere  is  any  possibility  of  the  patient  having  acquired  the  in- 
fection, even  some  years  previously. 


Malaria.  113 

The  accurate  diagnosis  of  tlie  malarial  parasite  is  a 
matter  of  great  importance  botli  as  regards  prognosis  and 
treatment,  as  the  possible  effects  of  a  benign  and  malignant 
quotidian  or  tertian  fever  are  widely  different  in  range  and 
severity.  It  is  not  likely  that  a  tertian  or  quartan  malaria 
will  be  mistaken  for  any  other  disease,  the  regular  periodicity 
is  so  striking  and  characteristic,  but  in  malaria  of  the  quoti- 
dian, remittent,  or  irregular  types,  while  the  association  of 
the  fever  with  splenic  enlargement  and  previous  residence  in 
malarious  districts  may  arouse  suspicion  although  the  patient 
falls  ill  in  a  non-malarious  country,  accurate  diagnosis  is  im- 
possible without  the  detection  of  the  infecting  parasite.  Even 
the  test  of  quinine-treatment  by  the  mouth  will  fail  in  certain 
obstinate  cases.  It  is  to  be  remembered  that  the  acquiring  of 
some  other  infectious  fever  may  in  some  cases  arouse  even  a 
long-dormant  malaria,  and  the  difHculties  in  diagnosis  pre- 
sented by  an  attack  of  enteric  fever  complicated  by  a  con- 
current attack  of  malaria  have  given  rise  to  the  name  "  typho- 
malarial  fever,"  which  has  been  frequently  given  to  such 
cases.  Only  careful  examination  of  the  blood  by  the  making 
of  cultures,  by  the  performance  of  Widal's  test,  and  by  the 
discovery  of  the  malarial  parasite  on  microscopical  examina- 
tion will  definitely  reveal  the  true  character  of  the  illness. 

Complications. —  In  certain  cases  of  intermittent  malaria 
of  a  "low"  or  "adynamic"  type,  profound  nervous 
depression,  rapid  blood-destruction,  hsemorrhages  from  various 
mucous  membranes,  and  local  gangrene  may  supervene  as 
complications.  The  hyperpyrexia,  cardiac  failure,  convul- 
sions and  loss  of  power  which  occur  in  some  malignant  infec- 
tions, are  so  much  a  part  of  the  algide  and  cerebral  types  of 
the  disease  that  they  cannot  well  be  classed  as  "complications." 

Sequelae.  — The  sequelse  of  repeated  attacks  of  malaria 
are  best  described  as  forming  a  part  of  the  "malarial 
cachexia,"  a  general  deterioration  of  health  associated  with 
anaemia,  enlargement  of  the  spleen  and,  most  usually,  with 
a  tendency  to  irregular  febrile  attacks,  especially  following 
chill  or  any  unusual  mental  or  physical  strain.     The  patient 


114  Chapter  VII. 

is  pallid  and  anaemic  looking,  with  a  peculiar  dull  yellowish 
colour  of  the  skin  and  very  frequently  some  yellow  tinting  of 
the  sclerotics.  This  condition  of  cachexia,  while  usually  fol- 
lowing on  repeated  attacks,  may  be  established  b}^  one  very 
severe  attack  of  the  disease,  and  may  even  result  from  pro- 
longed residence  in  a  malarious  district  without  the  patient 
having  had  any  recognisable  malarial  paroxysm.  The 
cachexia  may  be  present  without  fever,  although  this  is  not 
usual.  Splenic  enlargement  is  sometimes  enormous,  and  al- 
though the  "  ague-cake  "  is  frequently  firm  and  even  hard  on 
palpation,  rupture  from  very  slight  violence  of  a  chronically 
enlarged  spleen  the  result  of  malarial  infection  is  quite  com- 
mon. This  is  one  of  the  reasons  v/hy  "kicking  a  nigger"  is 
discouraged  by  European  administrations  in  Africa  and  India, 
while  among  natives  of  malarious  countries  a  blow  over 
the  spleen  is  a  favourite  w^ay  of  getting  rid  of  an  enemy.  In 
very  malarious  districts  splenic  enlargement  is  often  found  ia 
young  children,  and  it  is  even  said  that  infants  are  sometimes 
born  with  an  enlarged  spleen  as  the  result  of  chronic  malarial 
poisoning  of  the  mothers. 

Sometimes  when  malarial  cachexia  appears  in  childhood, 
development  is  greatly  retarded,  so  that  a  person  of  twenty- 
five  years  of  age  may  look  like  a  child  of  eleven  or  twelve. 

Malarial  cachectics  are  often  very  prone  to  severe  haemorr- 
hages. In  such  cases  a  very  slight  operation,  such  as  a  tooth - 
extraction,  may  give  rise  to  a  profuse  haemorrhage  which  may 
be  difficult  to  control,  and  the  greatest  care  must  be  taken,  in 
this  class  of  patient,  in  advising  or  performing  any  operation 
even  of  the  most  trivial  description.  Epistaxis,  hsematemesis, 
haematuria,  retinal  haemorrhages,  and  purpura  may  occur 
without  any  operative  interference,  and  such  occurrences  are 
of  grave  import,  indicating,  as  they  do,  a  very  profound 
degree  of  cachexia. 

Neuroses  of  various  kinds  have  been  observed  in  connec- 
tion with  the  malarial  cachexia,  and  the  striking  point  about 
them  is  that  they  may  be  definitely  periodic  in  their  occur- 
rence. We  may  see  quotidian^  tertian  and  quartan  attacks  of 
neuralgia,  pain  in  the  epigastrium,  vomiting,  headache,  and 
even  diarrhoea,  or  attacks  of  sneezing  and  palpitation.    Herpes, 


Malaria.  115 

erythema  nodosuTu,  urticaria,  und  eczema.  Lave  been  observed, 
and  in  a  few  instances  synovitis  Jias  been  noted,  all  sliowing  a 
periodic  tendency  to  exacerbation  and  improvin*^  under  treat- 
ment by  quinine. 

Perijilieral  neuritis  has  been  observed  associated  with  tlie 
presence  of  the  malignant  parasite  in  the  blood. 

Organic  changes  of  a  fibrotic  kind  in  heart,  kidney,  liver 
and  spleen  are  frequently  met  with  in  cases  of  long  continued 
cachexia,  and  cachectics  are  very  liable  to  hroncliial  catarrh 
and  hroncho-fmeumonia  as  a  result  of  chill. 

Blackwater  fever. — It  is  perhaps  against  the  convictions 
of  many  to  place  blackwater  fever  in  the  list  of  malarial 
sequelae,  but  it  is,  I  think,  more  unreasonable  to  class  it  as 
one  of  the  dangers  of  the  quinine  treatment  of  malaria.  The 
hsemoglobinuria  which  follows  so  rarely  on  the  taking  of  large 
doses  of  quinine  disappears  when  the  drug  is  withdrawn,  and 
this  is  very  far  from  being  the  case  in  blackwater  fever. 
Manson  chooses,  with  considerable  reason,  to  class  it  as  a 
separate  disease  pending  further  information.  But  there  is 
no  doubt  that  blackwater  fever  occurs  habitually  in  malarious 
districts  and  usually  attacks  a  patient  who  has  been  the  sub- 
ject of  some  degree  of  malarial  infection,  the  manifestations 
of  which  may  have  been  obscured  by  the  use  of  quinine.  The 
fact  that  it  has  become  apparently  more  common  in  recent 
years  in  the  West  Coast  of  Africa  and  in  British  Central 
Africa  may  be  due,  as  Crosse  suggested,  to  its  having  been 
only  recently  separated  clinically  from  the  "bilious  remit- 
tent" type  of  malaria.  Its  onset  and  course  are  similar,  and 
it  is  not  always  easy,  save  by  appropriate  chemical  tests,  to 
distinguish  a  very  deeply  bile-stained  urine  from  haemoglobi- 
nuria.  But  the  evidence  of  careful  observers  in  British  Cen- 
tral Africa  and  British  East  Africa  goes  to  show  that  it  is  at 
least  very  frequently  associated  with  the  presence  in  the  blood 
of  the  malignant  parasite  of  malaria,  and  that  it  tends  to 
yield  to  quinine  suitably  administered.  It  would  seem  that 
this  hsemorrhagic  type  of  malaria  is  influenced  by  certain 
local  conditions,  as  it  tends  to  appear  almost  in  epidemic 
form     in     certain     districts     in     Africa     which,     after     the 

I  2 


116  Chapter  VII. 

occurrence  of  numerous  cases  during  one  year,  may  be  prac- 
tically free  of  blackwater  fever  for  several  seasons.  But  this 
is  no  argument  against  its  being  of  malarial  origin,  as  anyone 
who  has  liad  experience  of  smallpox  will  remember  how  in  cer- 
tain epidemics  the  hsemorrhagic  type  of  the  disease  is  scarcely 
seen,  while  in  others  it  appears  with  uncomfortable  frequency. 
It  is  possible  that  certain  cases  of  blackwater  fever  may  be 
due  to  an  infection  other  than  malarial  and  may  bear  the 
same  relation  to  some  tick-borne  fever  as  others  bear  to 
malaria,  but  at  present  due  consideration  must  be  given  to 
the  opinion  expressed  by  Crosse  and  other  observers  in  Africa, 
that  in  the  majority  of  cases  it  is  due  to  an  infection  by  a 
malarial  parasite  and  will  yield  to  quinine,  since  their  ex- 
perience of  the  condition  as  met  with  in  Africa  must  far  out- 
weigh that  of  Koch  and  others  who  were  mere  visitors  to  the 
districts.  Certainly  in  the  one  case  which  I  have  seen,  the 
condition  appeared  in  a  man,  who  had  been  previously  the 
subject  of  a  malignant  malarial  infection,  several  months 
after  he  had  landed  in  Great  Britain,  during  which  time  he 
had  not  used  quinine.  The  malignant  parasite  was  present 
in  his  peripheral  blood  in  very  small  numbers,  extremely  diffi- 
cult to  detect,  and  the  condition  yielded  in  a  day  or  two  to 
intramuscular  injections  of  quinine.  It  seems,  on  the  other 
hand,  to  be  certain  that  in  some  cases  quinine  does  not  cure, 
even  when  given  properly,  but  the  objection  to  quinine  in  the 
treatment  of  blackwater  fever  by  those  who  have  given  it  only 
by  the  mouth    must  not  be  taken  too  seriously. 

Treatment. —  During  a  paroxysm,  the  patient  ought 
to  go  to  bed  as  soon  after  the  commencement  of  the  rigor  as 
possible,  and  remain  there  until  the  sweating  stage  is  over. 
Durinff  the  cold  sta^e  he  should  have  hot  drinks  and  be 
covered  warmly.  In  the  hot  stage,  his  discomfort  may  bo 
alleviated  by  tepid  or  cold  sponging,  and  headache  may  be 
relieved  by  the  application  of  cold  cloths  to  the  forehead. 
Should  vomiting  be  severe,  the  application  of  a  mustard 
poultice  or  mustard  leaves  to  the  abdomen  will  often  help  to 
check  it.  During  the  sweating  stage,  when  the  fever  is  de- 
clining, his  clothes  should  be  changed  rapidly  and  the  sur- 
face of  the  body  dried  as  occasion  needs,  and  any  tendency  to 


Malaria.  117 

collapse  may  be  met  by  hot  applications  over  tlie  lieait  and 
the  hypodermic  injection  of  strychnine  and  ether,  while  small 
doses  of  alcohol  by  the  snouth  or  rectum  may  be  called  for. 

In  the  intervals  between  the  paroxysms,  should  the  attack 
be  tertian  or  quartan,  the  patient  may  be  allowed  greater 
liberty,  but  it  is  well  to  discourage  any  great  physical  or 
mental  activity  until  the  attack  has  been  subdued  by  quinine. 
In  the  vast  majority  of  cases,  quinine,  properly  used,  will  cut 
short  the  attack,  so  that  only  one  or  two  paroxysms  may  occur. 
When  the  attack  is  of  the  tertian  or  quartan  type,  it  is  well 
to  withhold  quinine  until  the  paroxysm  is  over,  and  then  to 
give  it  in  solution  in  one  or  two  ways.  It  is  to  be  remembered 
that  the  commencement  of  the  paroxysm  coincides  with  the 
maturation  and  rupture  of  the  sporulating  forms  of  the 
parasite,  so  that  to  be  effective  in  checking  the  onset  of  the 
day's  paroxysm,  quinine  must  be  given  before  such  matura- 
tion can  occur,  thus  preventing  the  liberation  of  the  spores, 
both  to  anticipate  the  paroxysm  and  to  prevent  the  formation 
of  a  new  brood  of  the  parasite.  As  it  is  thought  that  the 
parasite  is  most  vulnerable  between  its  half-grown  and  its 
mature  stage,  it  is  the  practice  of  many  physicians  to  begin 
treatment  with  quinine  by  giving  one  large  dose  of  20-25 
grains  each  day  an  hour  or  two  before  the  time  at  which  the 
paroxysm  is  expected  to  occur,  and  this  method,  which  is  the 
one  used  largely  by  British  physicians  in  Spain,  is  certainly 
very  effective,  and  tends  less  to  the  saturation  of  the  tissues 
by  the  drug  than  the  employment  of  repeated  small  doses  ap- 
proved of  by  others.  It  has  one  disadvantage,  in  so  far  as  it 
may,  in  susceptible  persons,  produce  the  uncomfortable  S3'mp- 
toms  of  cinchonism — deafness,  ringing  in  the  ears,  headache, 
vomiting  and  an  intolerable  urticaria,  but  such  susceptible 
people  are  comparatively  rareh^  met  with,  and  if  the  patient  is 
at  rest  during  the  time  of  treatment,  severe  cinchonism  is  not 
very  likely  to  occur.  Those  who  prefer  to  use  quinine  in 
smaller  quantities  frequently  repeated,  give  doses  of  5  grains 
at  intervals  during  the  day,  beginning  just  after  the  sweating 
stage  is  ended,  until  30  grains  have  been  given.  Another 
method  of  administration  is  to  give  10  grain  doses  at  5  a.m., 
8  a.m.  and  11  a.m.  and  this  has  the  advantage  over  the  large 


118  Chapter  VII. 

single  dose  of  lessening-  the  risk  of  producing  cinclionism. 
Where  the  large  single  dose  is  used,  it  should  be  repeated  daily 
for  some  four  or  five  days.  The  dose  should  then  be  reduced 
by  one  half  and  given  for  a  week,  when  it  should  be  further 
reduced  by  one  half  and  continued  for  ten  days  or  a  fortnight. 
When  the  smaller  repeated  doses  are  employed,  they  should 
be  continued  regularly  for  a  week,  and  for  a  week  thereafter 
they  should  be  reduced  in  frequency  so  that  15  grains  are 
taken  in  the  twenty-four  hours,  while  for  yet  another  fort- 
night 10  grains  should  be  given  each  day. 

In  the  treatment  of  a  quartan  ague,  it  is  well  to  wait,  as 
in  the  case  of  a  tertian,  until  the  paroxysm  has  subsided  before 
giving  quinine,  and  if  the  large  single  doses  are  used  they 
must  be  continued  for  a  week,  and  reduced  in  a  corres- 
pondingly more  gradual  way  as  compared  with  a  tertian  at- 
tack. When  the  small  repeated  doses  are  used  the  initial 
number  should  be  continued  for  ten  days,  while  15  grains  daily 
should  be  continued  for  ten  days,  and  10  grains  daily  for 
another  fortnight.  The  different  types  of  malaria  behave  very 
differently  under  treatment.  A  benign  quartan  attack  is 
more  easily  checked  by  small  doses  of  quinine  than  a  benign 
tertian,  but  shows  a  much  greater  liability  to  relapse — while 
its  manifestations  are  very  easily  subdued,  it  is  difficult  to 
eradicate.  A  benign  tertian,  on  the  other  hand,  while  some- 
times rather  difficult  to  check,  shows  much  less  tendency  to 
relapse  after  reasonable  treatment. 

K  malignant  infection  is  the  'most  troublesome  of  all,  not 
only  because  of  its  comparatively  refractory  behaviour  towards 
quinine,  but  on  account  of  its  tendency  to  be  accompanied  by 
the  more  pernicious  symptoms  of  the  disease  and  its  liability 
to  induce  cachexia.  It  is  not  necessary  to  give  quinine  other- 
wise than  by  the  mouth  during  the  early  stages  of  a  mild 
malignant  infection,  but  it  should  be  given  as  soon  as  the 
diagnosis  is  made,  irrespective  of  the  presence  of  fever  at  the 
time.  On  the  slightest  hint  of  the  onset  of  nervous  symptoms 
as  indicated  by  drowsiness  or  coma,  restlessness  or  delirium, 
it  should  at  once  be  given  intramuscularly,  as  any  delay  in 
g'itting  the  patient  thoroughly  under  the  influence  of  quinine 


Malaria.  119 

may  result  in  his  deatli.  Similarly,  on  the  occurrence  of  any 
of  the  so-called  "  alg'ide  "  symptoms,  quiiiirio  must  be  given 
intramuscularly  or  intravenously  Avitbout  delay.  If  quinine 
is  being  given  by  the  mouth  and  the  malignant  attack  con- 
tinues, even  with  slight  febrile  manifestations  or  periodic 
neurotic  symptoms,  for  more  than  a  few  days,  it  is  well  to 
resort  to  intramuscular  or  intravenous  injections,  as  the 
danger  of  a  severe  cachexia  following  on  a  prolonged  malig- 
nant infection  is  considerable.  To  many,  these  recommen- 
dations may  appear  to  be  signs  of  over-anxiousness,  but  most 
people  who  have  seen  the  sudden  occurrence  of  nervous  symp- 
toms which  have  ushered  in  a  fatal  termination,  during  a 
rather  prolonged  but  apparently  mild  attack  of  malignant 
malaria,  will  agree  that  it  is  well  to  prevent  such  symptoms 
rather  than  to  be  compelled  to  treat  them.  It  is  impossible  to 
foretell  the  occurrence  of  cerebral  or  algide  symptoms,  and 
it  is  necessary  to  realise  that  they  may  appear  during  the 
course  of  any  malignant  infection,  however  apparently  mild 
its  manifestations  may  be.  Those  who  have  worked  in 
inalarious  districts  seem  to  acquire,  to  a  certain  extent,  that 
contempt  of  mild  attacks  which  is  born  of  over-familiarity, 
but  it  may  be  taken  as  true  that  many  deaths  from  malaria, 
and  many  cases  of  malarial  cachexia,  are  absolutely  prevent- 
able if  the  patient  is  able  to  take  sufficient  care  and  the  phy- 
feician  is  alive  to  the  importance  of  accurate  diagnosis  and 
prompt  and  efficient  treatment.  Quinine  should  never  be 
given  by  the  mouth  in  powder  or  pill,  but  in  solution,  and 
the  most  convenient  salt  to  use  is  the  bi-hydrochloride,  which 
has  a  solubility  in  water  of  1  in  I.  This  salt  is  less  irritating 
to  the  stomach  than  the  sulphate,  and  its  solubility  lessens 
the  possibility  of  the  quinine  not  being  absorbed.  It  is  most 
probable  that  much  of  the  enormous  doses  of  the  sulphate  of 
quinine  in  powder,  said  to  have  been  taken  either  for  curative 
or  prophylactic  purposes,  never  dissolved  at  all,  but 
passed  through  the  body  pretty  much  as  it  was  ingested.  The 
same  salt  is  convenient  for  intramuscular  injection,  and 
should  be  gi^'en  in  doses  of  from  T-10  grains  dissolved  in 
30-60  minims  of  water  repeated  in  severe  cases  two  or  three 
times  in  the  day.     Intramuscular  injections   should  be  con- 


120  Chaper  VII. 

tinned  for  a  m  eek,  the  best  site  for  injection  being'  the  gluteal 
region,  care  being  taken  to  aToid  large  nerves. 

Bacelli,  one  of  the  best  known  of  Italian  physicians,  uses 
the  bi-hydrochloride  of  quinine  1  gramme,  sodium  chloride  75 
centigrammes,  with  distilled  water  10  grammes,  as  a  solution 
for  intravenous  injection  in  malaria  of  a  pernicious  comatose 
remittent  type.  He  injects  into  a  vein  from  5-7  grammes  of 
the  solution  at  a  time,  and  states  that  he  has  reduced  his 
death-rate  in  such  cases  to  6  per  cent.,  as  against  the  death- 
rate  of  17  per  cent,  which  he  had  when  he  employed  the  intra- 
muscular injection. 

Calomel  should  be  given  in  doses  of  3-5  grains  at  the  com- 
mencement of  treatment,  and,  as  in  all  fevers,  free  movement 
of  the  bowels  at  the  beginning  of  an  attack  is  good  practice. 
In  all  cases  of  malaria,  when  a  few  hours'  delay  in  the 
beginning  of  treatment  with  quinine  is  at  all  justifiable,  it  is 
well  to  give  calomel  or  blue-pill,  followed  hj  a  saline  aperient, 
before  giving  quinine.  In  this  way,  the  risk  of  the  occurrence 
of  cinchonism  is  greatly  lessened. 

Algide  and  dysenteric  syvi'ptoms  require  the  use  of  small 
doses  of  opium  as  well  as  quinine.  Hyiierpyi'e.via  should  be 
treated  by  prolonged  immersion  in  a  tepid  or  cold  bath  while 
ice  is  applied  to  the  head. 

Malarial  Cachexia. — The  treatment  of  malarial  cachexia 
resolves  itself  into  attacking  the  malarial  parasite  with 
quinine  if  it  be  present,  preferably  by  intramuscular  injec- 
tions, and  dealing  with  the  anaemia  by  the  use  of  arsenic  and 
iron,  while  special  conditions  may  call  for  special  treatment. 
Malarial  cachectics  should  leave  malarious  districts  and  spend 
at  least  one  year  in  a  temperate,  non -malarious  country.  They 
should  scrupulously  avoid  chill  and  damp,  and  ought  to  clothe 
themselves  warmly  and  pay  particular  attention  to  wet  feet. 
Quinine  should  be  taken  for  two  or  three  months  after  leaving 
malarious  districts. 

The  enlarged  spleen  is  best  treated  by  counter-irritation, 
using  either  Jinimentum  iodi  or  unguentum  hydrargyri 
biniodidi,  or  a  more  heroic  practice  may  be  resorted  to,  which 
is  sometimes  very  successful,  the  injection  of  20-30  minims  of 
turpentine  subcutaneously  into  the  abdominal  wall  overlying 


Malaria.  121 


iU 


the  splenic  enlargement.  This  produces  a  species  of  abscess- 
formation,  and  is  frecjuently  followed  by  a  reduction  in  the 
size  of  the  organ. 

Hepatic  enlargement  and  congestion  are  best  dealt  witli 
by  a  course  of  treatment  at  Carlsbad,  Kissingen,  Vittel,  or 
Harrogate,  but  when  this  is  not  possible,  it  is  well  to  gi\e  the 
patient  systematic  treatment  by  saline  aperients  in  the  morn- 
ing for  several  weeks. 

The  treatment  of  blackwater  fever  is,  as  has  been 
already  seen,  a  very  vexed  question.  Where  the  belief  is 
held,  as  in  the  case  of  Koch,  that  blackwater  fever  is  definitely" 
due  to  previous  treatment  by  quinine,  that  drug  will  naturally 
be  withheld,  and  treatment  by  arsenic  or  other  drugs  sub- 
stituted. Where,  however,  its  origin  is  believed  to  be  mainly 
malarial,  especially  if  even  a  very  few  parasites  are  discovered 
in  the  blood,  quinine  will  be  employed.  The  results  obtained 
by  many  physicians  in  British  Central  Africa  certainly  justify 
the  serious  trial  of  quinine,  but  the  quinine  must  be  giveu 
intramuscularly  and  in  a  similar  dosage  as  is  employed  in  a. 
severe  remittent  case  of  malignant  malaria,  or  Bacelli's  intra- 
venous method  may  be  employed.  At  the  same  time  it  is  best 
to  withhold  all  food  by  the  mouth  and  give  alcohol  by  the- 
rectum,  alternating  with  small  rectal  injections  of  physio- 
logical salt  solution. 

Diet. — During  the  febrile  stage  of  the  disease,  whether 
the  infection  be  benign  or  malignant,  the  diet  should  consist 
of  clear  soups  and  milk  diluted  with  barley-water  or  rice- 
water,  and  during  the  earlier  stages  of  treatment  by  quinine* 
a  very  light  diet  consisting  as  far  as  possible  of  carbohydrates, 
fish,  eggs  and  chicken  should  be  employed.  While  there  is. 
no  reason,  in  most  cases  of  malarial  cachexia,  why  meat, 
should  be  Avithheld,  it  should  be  given  very  plainly  cooked, 
grilled  for  preference,  and  in  moderate  quantities.  In  cer- 
tain cases  of  cachexia,  especially  those  associated  with  organic 
disease  of  the  kidneys  and  liver,  the  diet  must  be  restricted 
as  in  the  earlier  stages  of  treatment  by  quinine,  while  in  others, 
the  extreme  irritability  of  the  stomach  will  prevent  any  diet 
other  than  milk  and  milk-foods  being  tolerated.  When  con- 
valescence is  thoroughly  established  as  full  and  generous  a 


i22  Chapter  VII . 

diet  as  is  within  the  patient's  toleration  should  be  given.  It 
may  be  necessary  in  cases  Math  obstinate  vomiting  to  give  the 
stomach  absolute  rest  while  the  vomiting  is  present,  and  feed 
the  patient  entirely  by  the  bowel. 

Epidemiology.  —  Malaria  is  endemic  in  most  parts 
of  the  Avorld  to-day  save  in  the  very  cold  latitudes,  but  is 
more  prevalent  in  warm  than  in  temperate  climates  and  more 
prevalent  in  sub-tropical  and  tropical  countries  than  in  the 
merely  warm.  Tertian  malaria  has  a  practically  universal 
distribution,  but  the  other  two  types,  the  quartan  and  malig- 
nant, are  not  so  universally  distributed,  the  quartan  being 
commoner  in  temperate  and  fairly  warm  countries,  while  the 
malignant  is  more  prevalent  in  sub-tropical  and  tropical  dis- 
tricts. In  those  warm  countries,  not  sub-tropical,  in  which 
malignant  malaria  appears,  as  in  Spain  and  Italy  and  parts 
of  the  United  States  of  America,  its  prevalence  is  governed  to 
some  extent  by  the  season  of  the  year,  first  cases  tending  to 
appear  in  late  summer  and  early  autumn,  and  for  this  reason 
the  name  "  Aestivo- Autumnal  "  has  been  given  to  the  type. 
Malaria  is  much  less  prevalent  in  Europe  than  it  used  to  be, 
on  account  of  the  improved  drainage  and  sanitation  which 
has  been  introduced  into  most  Western  countries  during  the 
past  century.  Chill  is  a  predisposing  element  in  the  pro- 
duction of  an  attack,  and  while  in  merely  warm  countries  a 
first  attack  of  malignant  malaria  may  be  acquired  in  summer 
or  autumn,  the  chills  of  winter  and  spring  may  induce  a 
second  attack  when  the  infection  is  latent,  and  in  those  who 
come  to  cold  or  temperate  climates  after  residence  in  malarious 
districts  the  determining  factor  in  the  production  of  another 
attack  may  be  the  arrival  in  England  or  the  Northern  parts  of 
America  during  the  cold  weather. 

In  temperate  climates  malaria  is  frequently  associated 
with  the  presence  of  swamps,  but  in  warmer  regions  this  is 
not  so  marked,  although  the  existence  of  pools  of  still  water 
are  absolutely  necessary  to  the  breeding  of  the  mosquito  with 
which  malaria  is  so  closely  connected.  In  some  districts  the 
rainy  seasons  are  malarious,  in  others  malaria  is  less  during 
the  rains.  This,  as  Manson  points  out,  is  simply  due  to  the 
fact   that   in    some    districts   the    rains    wash    out    the    local 


Malaria.  123 

mosquito-pools  and  in  others  are  just  sufficknit  to  fi]l  tlicrn.  I'Ik; 
disturbance  of  soil  in  malarious  districts  is  often  productive 
of  a  marked  outbreak  of  the  disease.  The  reason  for  this  is 
not  at  first  apparent,  Init  to  quote  Manson  again,  "  soil  dis- 
*'turbance  usually  means  tlie  formation  of  holes;  holes  imply 
"  puddles,  and  puddles  imply  mosquitoes.  Workmen  from 
^'  many  districts,  some  of  them  malarious,  are  assembled  in 
*' crowded  lodgings;  one  infected  workman  suffices  to  start 
"  the  epidemic. 

Method  of  Infection. — The  work  of  Manson  and  of 
Ross  has  placed  it  beyond  argument  that  the  mosquito  is  an 
essential  factor  in  the  infection  of  man  by  the  malarial  para- 
site. The  mosquitoes  whicli  have  been  found  to  act  as  inter- 
mediary hosts  of  the  parasite  belong  to  the  group  Anophelinse, 
and,  so  far,  no  other  group  of  the  mosquito-family  has  been 
found  to  be  capable  of  carrying  the  malarial  parasite.  When 
a  mosquito  sucks  infected  blood  into  its  stomach  the  sexual 
forms  of  the  malarial  parasite  appear  as  hyaline  or  male,  and 
granular  or  female,  spheres.  The  male  spheres  exflagellate 
and  the  detached  flagella,  or  iidcro gametes,  penetrate  a  granu- 
lar sphere  or  macro  gamete.  The  conjugation  of  these  two 
bodies  results  in  the  formation  of  a  lanceolate  form  capable  of 
movement,  which  penetrates  the  wall  of  the  mosquito's 
stomach  and  comes  to  rest  between  the  longitudinal  and 
transverse  muscular  fibres.  The  parasite  then  acquires  a  cap- 
sule, and  develops  in  its  interior  a  great  number  of  spindle- 
shaped  bodies,  which  after  the  rupture  of  the  capsule  are  set 
free  in  the  body  of  the  mosquito.  From  there  they  pass, 
probably  by  the  blood-stream,  into  the  salivary  glands  which 
communicate  with  the  base  of  the  mosquito's  proboscis  by  a 
long  duct.  The  spindle-shaped  bodies,  or  sporozoites,  are  in- 
troduced into  tlie  blood  of  a  patient  through  the  duct  and 
proboscis  by  the  action  of  the  mosquito  in  biting,  and  then 
penetrate  the  red  blood  corpuscles  and  develop  into  one  or 
ether  of  the  malarial  parasites  of  the  tj^pes  already  described. 

Home  Prophylaxis. — This  consists,  in  the  main,  in  house- 
hold and  personal  cleanliness,  in  seeing  that  there  is  no 
standing  water  in  the  neighbourhood  of  the  house,  either  on 
the    ground    or    in    vessels,    and    in    the    scrupulous    use   of 


124  Chapter  VII. 

mosquito-uettiug  and  avoidance  of  infected  areas — in  otlier 
words,  in  doing  everything  to  avoid  being  bitten  by  mosquitoe* 
and  to-  prevent  the  breeding  of  mosquitoes  near  the  house.  The 
native  quarters  of  insanitary  towns  and  in  the  country  should 
be  avoided,  especially  in  the  dusk  and  dark,  as  the  mosquito 
is  most  active  at  these  times.  Houses  made  mosquito-proof 
by  having  mosquito-netting  over  doors  and  windows,  are  being 
frequently  used  in  malarious  districts,  and  steamships  are 
being  rendered  proof  in  a  similar  way.  At  the  same  time, 
residents  in  malarious  districts  are  well  advised  to  avoid  the 
evening  and  morning  chill,  which  is  a  predisposing  cause  iii 
malarial  infection,  and  the  use  of  quinine  as  a  prophylactic 
is  to  be  encouraged.  From  three  to  five  grains  of  the  bi- 
hydrochloride  should  be  taken  daily  in  the  morning,  or  ten 
grains  twice  a  week,  or  fifteen  grains  every  ten  or  eleven 
days.  Each  method  has  its  advocates,  but  the  small  daily 
dose  is  probably  the  best.  People  who  show  intolerance 
of  quinine  should  not  go  to  malarious  countries. 

Public  Health  Administration.— The  duties  of  the  medical 
oificer  in  malarious  districts  are  to  educate  his  people 
in  the  "  mosquito-malarial  theory,"  to  distribute  quinine 
among  those  too  poor  to  buy  it  and  to  take  measures  to  eradi- 
cate the  mosquito.  Each  one  of  these  duties  is  important.  It 
has  been  shown  in  British  Colonies  that  the  belief  in  the  mos- 
quito-malarial theory  on  the  part  of  the  governor  has  been 
half  the  battle  in  freeing  a  district  from  malaria,  while  an 
obstinate  and  unbelieving  set  of  ofl&cials  have  made  the  efforts 
of  the  medical  officer  of  no  avail.  The  distribution  of  quinine 
among  the  poorer  people  tends  to  lessen  the  field  of  infection 
for  the  mosquito,  which  is  a  result  of  some  value.  The  war 
against  the  mosquito  resolves  itself  into  draining  swamps  as 
far  as  possible,  either  directly,  or  by  planting  large  trees  of 
tho  "blue -gum  "  type,  and  in  removing  all  pools  and  standing 
water  collected  in  such  disused  vessels  as  tins,  broken  pots, 
&c.  When  pools  cannot  be  drained  and  filled  up,  as  in  the 
residual  pools  in  river-beds,  it  is  enough  to  cover  their  sur- 
face weekly  with  petroleum,  which  prevents  the  mosquito  from 
settling  to  deposit  the  ova,  and  asphyxiates  the  larvae  which 
have  already  hatched  in  the  pools  and  which  must  come  to 
the  surface  to  breathe. 


BiffllHI  liiEE!dSg 


(     125   ) 


Chapter  VIII. 

EPIDEMIC    CEREBROSPINAL 
MENINGITIS. 

Synonyms. — Spotted   fever ;  Epidemic   cerebro-spinal  fever. 
Fr.  :      Mening'ite  cerebro-spinale    epidemique. 
Ger.  :      Epidemisclie  Genickstarre. 

Definition.  —  An  acute  infectious  fever,  associated  with 
an  inflammation  of  the  cerebral  and  spinal  meninges  due  to 
an  infection  by  the  Diplococcus  rneningitidis  intracellularis 
discovered  by  Weichselbaum  in  1888. 

Incubation  Period. — The  incubation  period  seems  to  vary 
from  one  to  twenty-eight  days,  but  the  usual  latent  period  is 
apparently  about  two  to  ten  days,  although  it  is  extremely 
difficult  to  be  accurate  on  this  point. 

Rash. — Although  the  name  "  spotted  fever  "  has  been 
given  to  epidemic  cerebro-spinal  meningitis,  the  hsemorr- 
hagic  eruption  which  apparently  gave  rise  to  the  name  has 
been  seen  comparatively  infrequently  during  recent  epidemics. 
Billings  of  New  York  states  that  it  occurred  in  only  10  per 
cent,  of  the  cases  which  he  analysed,  Claude  Baker  gives  22 
as  his  percentage,  Avhile  in  Glasgow,  during  1906  and  190T 
the  percentage  of  cases  in  which  the  petechial  rash  appeared 
was  10.9  in  1906  and  21  in  1907,  giving  an  average  percentage 
of  15.95.  The  eruption  appears  usually  somewhere  between 
tbe  first  and  fifth  days  of  illness,  most  commonly  on  the  third 
or  fourth.  Its  duration  is  short,  only  three  or  four  days 
elapsing  between  the  appearance  of  the  petechia?  and    their 


126  Cha2)te,r:VIII. 

fading.  Tlie  rash  lias  a  very  generalised  distribution,  but 
may  be  more  profuse  over  the  lower  part  of  the  abdomen,  and 
inner  side  of  the  thighs.  It  is  composed  of  small  haemorr- 
hages into  the  skin,  of  a  bright  purple  colour,  varying  in  size 
usually  between  a  pin's  head  and  ^  of  an  inch  in  diameter, 
although  it  is  not  uncommon  to  find  spots  of  the  size  of  a 
shilling  and  even  larger.  Haemorrhages  into  the  conjunc- 
tivae are  occasionally  seen.  A  similar  eruption  to  this  appears 
sometimes  just  before  death. 

The  occurrence  of  a  haemorrhagic  eruption  is  a  very 
ominous  sign.  During  the  Glasgow  epidemic  of  1906  and 
1907  only  one  case  which  had  haemorrhages  into  the  skin  re- 
covered, and  in  this  case  fever  lasted  for  160  days,  while 
recovery  took  place  with  complete  deafness.  In  a  few  cases 
a  mottling  of  the  skin  like  the  subcuticular  mottling  of  typhus 
has  been  noted,  both  apart  from  and  in  conjunction  with  the 
petechial  rash. 

An  herpetic  eruption  distributed  about  the  angles  of  the 
mouth,  on  the  cheek,  the  ears,  or  alae  of  the  nose,  appears 
with  just  about  the  same  frequency  as  the  petechial  rash  with 
which  it  is  sometimes  associated.  It  usually  makes  its  ap- 
pearance on  the  second  or  third  day  of  illness,  but  may  be 
deferred  until  the  second  week.  In  some  cases  it  makes  its 
first  appearance  at  the  beginning  of  a  relapse,  and  in  others 
when  it  has  appeared  at  the  beginning  of  the  attack  it  re- 
appears when  a  relapse  occurs.  A  blotchy  erythematous 
eruption  of  quite  irregular  distribution  is  sometimes  met  with, 
and  Osier  mentions  a  deep  livid  erythema  accompanied  by 
blood-filled  vesicles  as  occurring  occasionally  on  the  ex- 
tremities. 

Clinical  Types. — The  onset  of  the  disease  is  sudden,  and 
in  most  cases  the  attack  is  ushered  in  by  the  sudden  occur- 
rence of  headache  and  vomiting,  sometimes  accompanied  by 
rig-or,  or  in  children  by  convulsions.  Extreme  vertigo  has 
been  observed  as  a  symptom  of  onset.  In  some  cases  the  acute 
symptoms  may  be  preceded  by  a  few  days  of  general  malaise, 
or  sore  throat,  or,  very  occasionally,  of  nasal  catarrh.  Shortly 
after  the  occurrence  of  the  initial  symptoms  the  patient  may 
complain  of  stiffness  and  pain  in  the  neck,  and  retraction  of 


Ejndeviic  Ccrebro-Spinal  Meningitis.  127 

the  liead  may  be  noticed  even  in  patients  who  are  still  able  to 
walk  about.  The  teiwperatura  is  usually  elevated  from  the 
start,  but  may  fall  to  normal  within  the  first  day,  although  it 
is  common  to  have  a  certain  amount  of  fever  present  through- 
out the  attack.  It  follows  no  regular  curve,  and  the  height 
of  the  fever  is  no  measure  of  the  severity  of  the  attack.  In 
some  cases  it  rises  rapidly  to  105°  F.  or  more  just  before 
death,  but  in  many  of  the  most  acute  cases  death  occurs 
during  the  first  week  with  a  normal  or  subnormal  tempera- 
ture. In  a  large  number  of  cases  the  fever  tends  to  be  high 
during  the  first  week  and  "  continued "  in  type,  while 
during  the  second  week  it  takes  on  a  marked  remittent 
type  which  may  end  abruptly,  or  gradually  terminate  by  a 
prolonged  lysis.  The  pulse  is  usually  increased  in  frequency, 
but  in  some  cases  its  rate  may  be  as  low  as  40  or  50  per 
minute,  and  it  is  common  to  have  extraordinary  daily  varia- 
tions in  the  same  patient,  having  little  apparent  connection 
with  variations  in  the  temperature.  Before  death  the  pulse 
becomes  rapid  and  feeble  and  may  be  very  irregular,  and  in 
the  more  chronic  cases  it  is  usually  rapid,  irregular  and  indi- 
cative of  low  pressure. 

In  general,  the  disease  presents  acute,  chronic  and  mild 
types. 

The  acute  type  is  characterised  by  severe  initial  symp- 
toms. Pain  in  the  head,  neck  and  back  is  complained  of, 
especially  on  movement,  Kernig's  sign  is  frequently  present 
and  delirium,  with  more  or  less  coma,  develops  within  the 
first  twenty-four  hours.  The  face  is  flushed  and  may  be  very 
dusky,  with  suffusion  of  the  conjunctivae,  w^hile  the  patient 
has  an  anxious,  suffering  look. 

In  young  children  there  is  frequently  a  tendency  to  slight 
aching  in  the  back,  but  pronounced  opisthotonos  is  not  seen 
until  the  more  chronic  stage  is  reached.  The  knee-jerks  are 
frequently  exaggerated  before  the  onset  of  coma,  and  the 
plantar  reflex  is  exaggerated  but  definitely  flexor  in  type.  The 
patient  is  often  markedly  hypersesthetic,  shrinks  and  becomes 
restless  on  even  light  handling,  while  photophobia  is  often 
present.  The  condition  of  the  pupils  is  very  variable.  If 
delirium  is  present  they  are    usually    contracted,    if    coma. 


128  Chopter  VIII. 

dilated.  They  are  frequently  irregular,  and  a  degree  of 
hip  pus  is  sometimes  present.  A  variable  degree  of  squint  is 
very  common.  In  acute  cases  death  occurs  within  the  first 
fourteen  days,  not  uncommonly  on  the  fourth  or  fifth  day. 

The  chronic  type  has  an  onset  and  early  course  similar  to 
the  acute,  but  death  does  not  occur  during  the  first  fortnight. 
Instead,  there  comes  an  abatement  of  the  more  acute  symp- 
toms of  pain,  delirium  and  coma,  but  convalescence  does  not 
begin.  There  may  be  no  fever,  and  when  it  is  present  it  is 
iisuall}'  verj?-  irregular  in  type.  Opisthotonos  may  be  marked, 
and  a  progressive  wasting  sets  in.  In  some  cases  the  degree 
•of  emaciation  is  quite  extraordinary,  and  this  remarkable 
■degree  of  wasting  is  one  of  the  most  notable  features  in  all 
•cases  which  belong  to  the  chronic  type.  E-igidity  of  the  limbs 
is  a  very  common  symptom,  and  may  be  either  transient  or 
persistent.  Vomiting  is  another  symptom  that  is  at  times 
very  distressing,  although  it  may  not  interfere  with  appe- 
tite, which  is  usually  good. 

Twitching  of  the  face  and  limbs,  and  marked  muscular 
tremor  are  often  observed.  The  patient  may  become  com- 
pletely deaf,  and  there  may  be  some  otitis  media.  A 
hypersemia  of  the  optic  disc  has  been  observed  in  certain 
cases,  but  none  of  those  which  recoA^ered  during  the  Glasgow 
•epidemics  were  blind.  As  the  disease  proceeds  the  patient 
.after  a  tedious  period  of  wasting  and  enfeeblement  may  slowly 
recover,  gradually  losing  his  headache  and  rigidity  and  ten- 
dency to  vomit,  but  after  the  passing  away  of  all  symptoms 
he  may  be  unable  to  walk  for  weeks.  His  mental  condition  is 
often  much  enfeebled,  and  many  who  recover  are  permanently 
deaf.  Many  suffer  for  long  from  paresis  of  various  groups  of 
muscles.  Death  may  occur  after  a  prolonged  illness  of  many 
weeks  from  sheer  asthenia  and  progressive  wasting,  or  it  may 
be  ushered  in  by  the  occurrence  of  violent  convulsions. 

The  mild  type  of  the  disease  is  one  where  the  onset  is 
•quite  characteristic,  but  where  there  is  no  delirium  or  coma, 
although  retraction  of  the  head  and  even  opisthotonos  may  be 
present.  Such  cases  usually  recover  after  a  more  or  less 
chronic  course  without  any  of  the  more  serious  occurrences, 
such  as  wasting,  deafness  or  paresis. 


Epidemic  Cerehro-Spinal  Meningitis.  129 

The  abortive  type  is  a  name  which  may  be  given  to  a  class 
of  case  where,  although  the  onset  is  severe  and  acute,  the 
disease  terminates  favourably  within  the  first  week  or  ten 
days,  with  rapid  subsidence  of  all  the  symptoms  and  none  of 
the  dreary  happenings  of  the  chronic  type. 

Relapses  are  not  uncommon,  and  may  be  very  numerous, 
as  many  as  a  dozen  having  been  observed.  The  relapses  are 
not  usually  as  severe  as  the  initial  attack,  and  each  succeed- 
ing relapse  tends  to  be  milder  than  its  predecessor. 

Complications.  —  The  only  occurrence  during  the  course  of 
cerebro-spinal  fever  which  may  be  classed  as  a  complication 
is  the  occurrence  of  chronic  hydrocephalus.  This  is  met 
with  not  infrequently,  appearing  somewhere  about  the  third 
week.  The  condition  is  indicated  by  an  enlargement  of  the 
head,  all  the  more  striking  when  compared  with  the  emaciated 
face.  The  eyes  have  a  fixed  staring  look,  and  there  is  a  ten- 
dency to  retractation  of  the  upper  eye-lid.  Nystagmus  and 
hippus  may  be  present,  and  optic  neuritis  is  always  found. 

The  hypostatic  congestion  of  the  lungs  which  sometimes 
occurs  in  chronic  cases  can  scarcely  be  described  as  a  com- 
plication, as  it  is  due  to  the  failure  of  the  heart  which  is  so 
marked  a  feature  in  such  cases. 

Sequelae.  —  Many  of  the  cases  which  recover  are  deaf  and 
mentally  deficient.  The  mental  deficiency  may  in  some  in- 
stances become  less  noticeable  as  health  is  established,  but 
the  deafness  is  always  permanent.  A  very  marked  degree  of 
muscular  weakness  is  present  for  a  long  time  in  such  cases  as 
survive  a  chronic  attack,  but  this  is  not  a  marked  feature  in 
those  whose  attack  has  been  abortive. 

Diagnosis.  —  Apart  from  association  and  the  occurrence 
of  the  petechial  rash  there  is  nothing  to  distinguish  an  at- 
tack of  epidemic  cerebro-spinal  meningitis  from  any  other 
acute  meningitis  affecting  the  posterior  basal  region  and  the 
spinal  cord,  and  only  the  course  of  the  case  may  arouse  sus- 
picion. A  fulminant  case  of  typhus  may  closely  simulate  a 
case  of  cerebro-spinal  meningitis,  although  it  is  unusual  to 
have  headache  persisting  through  delirium  in  any  condition 
other  than  a  meningeal  inflammation.       x\ccurate  and  early 


K 


130  diaper  Vlll. 

diagnosis  must  depend  on  the  result  of  the  examination  of  the 
cerebro-spinal  fluid,  and  the  importance  of  this  examination 
cannot  be  too  much  emphasised,  especially  as  in  the  early 
stages  treatment  by  serum  may  offer  some  hope.  In  every 
case  in  which  meningitis  is  suspected,  the  cerebro-spinal  fluid 
should  be  examined  by  lumbar  puncture  without  delay.  Punc- 
ture is  usually  made  in  the  space  between  the  third  and  fourth 
or  between  the  fourth  and  fifth  lumbar  vertebrse,  the  land- 
mark being  the  line  drawn  between  the  summits  of  the  crests 
of  the  iliac  bones.  In  this  region  nothing  is  likely  to  be  in- 
jured by  the  needle  save  a  cord  of  the  cauda  equina.  A. 
needle  of  some  four  or  five  inches  long  with  a  large  bore 
similar  to  those  used  with  serum  syringes  should  be  used  for  the 
purpose.  The  patient  may  sit  up,  if  he  is  able,  or  he  may 
lie  on  his  side.  The  back  should  be  flexed  as  much  as  pos- 
sible, and  if  the  patient  is  delirious  it  may  be  necessary  to 
have  the  assistance  of  two  or  three  attendants  to  hold  him  in 
position.  Lumbar  puncture  in  cases  of  tabes  dorsalis  and 
general  paralysis  is  performed  easily  after  freezing  the  part 
to  be  punctured  by  means  of  the  ethyl-chloride  spray,  but  on 
account  of  the  hypersesthesia  present  in  cerebro-spinal  menin- 
gitis the  process  of  freezing  is  usually  as  painful  as  puncture, 
and  it  may  be  necessary  to  give  a  general  anaesthetic  before 
the  operation  can  be  performed  with  safety.  A  little  chloro- 
form is  well  borne.  In  the  case  of  an  adult  who  is  not  very 
restless,  it  may  be  enough  to  administer  \  gr.  of  morphine 
hypodermically  a  short  time  before  puncture  is  made.  In 
young  children  the  interspace  selected  may  be  punctured  in 
the  middle  line,  but  in  older  children  and  in  adults  it  is  best 
to  introduce  the  needle  about  f  in.  to  \  in.  to  the  right  or 
left  of  the  middle  line,  between  the  laminae,  and  give  the 
needle  an  inward  and  upward  inclination.  The  needle  should 
be  introduced  firmly  and  slowly,  carefully  avoiding  bone, 
until  the  fluid  flows.  The  depth  to  which  the  needle  must 
penetrate  varies  from  1\  inches  in  a  young  child  to  some  three 
or  four  inches  in  an  adult.  In  cerebro-spinal  meningitis  ths 
fluid  most  commonly  spurts  out  with  considerable  force,  on 
account  of  increased  pressure  in  the  subarachnoid  space,  but 
it  may  flow  only  in  drops.       The  fluid  should  be  caught  in  a 


Epidemic  Cerebro-Spinal  Meninf/itis.  131 

sterile  tube  stoppered  by  sterile  cotton-wool,  and  set  aside  for 
future  examination.  The  needle  should  then  be  withdrawn, 
and  the  puncture  sealed  with  a  little  sterile  g-auze  and  collodion. 
The  skin  should  be  carefully  cleaned  and  the  needle  boiled  be- 
fore puncture.  Soap  and  water  followed  by  an  application  of 
acetone  may  be  used  to  cleanse  the  skin.  A  very  purulent 
and  sticky  exudate  may  refuse  to  flow  through  the  needle 
even  when  it  is  undoubtedly  in  the  subarachnoid  space,  and 
when  fluid  does  flow,  the  quantity  obtainable  varies  very 
much.  Sometimes  a  few  cubic  centimetres  is  all  that  can  be 
obtained,  while  at  others  as  much  as  50  or  60  cubic  centi- 
metres are  obtained  with  ease. 

A  very  few  cubic  centimetres  is  enough  for  bacteriological 
examination,  and  it  is  only  when  lumbar  puncture  is  used  for 
therapeutic  as  well  as  diagnostic  purposes  that  a  large  amount 
is  withdrawn.  The  fluid  during  the  acute  stage  of  an  attack 
is  always  more  or  less  turbid,  but  this  turbidity  varies  from 
a  mere  cloudiness  to  a  thick  purulent  exudate.  For  bacterio- 
logical examination  the  fluid  should  be  centrifugalised  and 
smear-preparations  and  cultures  on  ascitic  agar  made  from  the 
sediment.  The  smear-preparations  should  be  stained  by 
Jenner's  method  and  examined  microscopically.  The  cellu- 
lar elements  in  the  cerebro-spinal  fluid  in  a  case  of  epidemic 
cerebro-spinal  meningitis  are  mainly  polj'-morphoneuclear,  as 
in  the  acute  stage  of  all  meningitis,  whether  of  tubercular  or 
pyogenic  origin,  and  the  differentiation  depends  on  the  recog- 
nition of  Weichselbaum's  diplococcus  intracelluloris .  As  the 
name  implies,  this  diplococcus  is  found  in  the  protoplasm  of 
the  polymorphoneuclear  leukocytes,  but  it  is  also  found  in 
considerable  numbers  free  in  the  fluid.  Morphologically  it 
presents  the  appearance  of  two  small  bean-like  cocci  lying- 
with  their  concave  sides  towards  each  other,  closely  resem- 
bling the  gonococcus.  The  polymorphoneuclear  leukocytes 
are  usually  somewhat  degenerated  and  may  show  marked 
vacuolation.  When  puncture  is  made  during  the  chronic 
stage,  the  fluid  may  be  quite  clear,  but  in  contrast  to  the 
clear  fluid  obtained  in  cases  of  tuberculous  meningitis,  the 
cellular  elements  continue  to  be  polymorphic  and  not  lym- 
phocytic. 

K   2 


132  Chapter  VIII. 

Ag glutination  of  the  diplococcus  intra cellularis  from  cul- 
ture by  the  blood  serum  of  a  patient  suffering  from  cerebro- 
spinal meningitis  lias  been  shown  to  take  place,  but  this  re- 
action is  not  always  present  and,  indeed,  is  seldom  present  in 
the  very  early  days  of  the  disease,  so  that  its  use  is  confined 
to  the  recognition  of  cases  which  come  under  observation  after 
having  been  ill  for  some  time.  A  disadvantage  of  the  re- 
action as  a  test  is  that  it  is  obtained  with  great  variability  in 
even  moderately  high  dilutions,  and  a  dilution  of  only  1-3  or 
1-5  must  be  employed  to  obtain  it  with  any  certainty. 

The  opsonic  index  of  the  patient  to  the  diplococcus  intra- 
cellularis  is  usually  raised  and  may  be  very  high. 

Treatment. —  Apart  from  the  giving  of  antitoxic  serum, 
the  treatment  of  cerebro-spinal  meningitis  must  be  purely 
symptomatic  and  palliative.  It  will  be  necessary  to  relieve 
pain,  lessen  restlessness  and  control  delirium  during  the  acute 
manifestations  and  to  maintain  strength  during  the  chronic 
stage.  Morphine  in  small  doses  hypodermically  will  quiet 
restlessness,  relieve  pain  and  induce  sleep,  but  it  has  been 
observed  that  after  its  use  patients  tend  to  become  comatose, 
and  many  physicians  prefer  to  use  small  doses  of  chloral 
hydrate  in  combination  with  sodium  bromide,  repeated  at 
frequent  intervals,  to  quiet  the  patient,  and  to  rely  on  other 
methods  for  the  relief  of  pain.  Cold  applications  to  the  neck 
and  spine  have  been  advocated  when  pain  is  severe,  but  the 
majority  of  cases  so  resent  cold  that  the  applications  can  be 
made  only  for  very  short  periods  and  are  quite  ineffectual. 
Claude  Ker,  of  Edinburgh,  advocates  the  use  of  a  hot  bath 
when  patients  are  restless  and  in  pain,  and  his  experience  is 
that  after  a  bath  a  patient  may  get  some  hours'  sleep  and 
freedom  from  pain.  This  method  of  treatment  is  possible  in 
a  private  house  as  in  hospital.  Several  baths  should  be  given 
in  the  course  of  the  day,  and  each  bath  should  be  of  about 
half-an-hour's  duration. 

But  the  death-rate  shows  how  futile  palliative  treatment 
is  in  the  case  of  cerebro-spinal  meningitis,  and  one  must  look 
to  some  form  of  serum-therapy  to  make  treatment  at  all  hope- 
ful. Anti-meningococcal  serum  has  been  made  by  KoUe  and 
Wassermann,  Ruppel,  and  Burroughs,  Wellcome  &  Co.,  and 


Epidemic  Cerehro-Sjnnal  Meningitis.  133 

all  these  sera  were  used  in  ]}elvidere  llospita],  Glasgow, 
between  May,  1906,  and  May,  1908,  and  the  result  of  treatment 
recorded  by  Curri©  and  Macgregor  in  "  The  Lancet "  in 
October,  1908.  The  sera  were  given  subcutaneously,  intra- 
venously and  intrathecally,  but  the  results  following  on  their 
use  were  not  very  encouraging,  the  death-rate  all  over  being 
74.8  per  cent.  Gardiner  Robb  published  in  1909  tlie  results 
of  his  experience  Avitli  Flexner's  serum  in  Belfast, 
and  the  apparent  reduction  of  the  death-rate  in  that  city 
from  70  to  30  per  cent,  would  seem  to  offer  some  hope  that 
serum-therapy  properly  used  may  afford  a  weapon  of  some 
power  to  fight  this  most  deadly  disease.  But  it  must  be 
remembered  in  comparing  the  results  of  on©  man  in  one  place 
with  those  of  another  man  in  a  different  place,  that  the  type 
of  epidemic  in  the  first  place  may  have  been  quite  different 
from  that  in  the  second,  and  it  is  only  after  the  careful  study 
of  the  results  obtained  by  the  same  serum  in  many  different 
epidemics  that  we  can  properly  arrive  at  its  true 
value.  Serum  ought  always  to  be  given  intrathecally. 
Lumbar  puncture  should  be  made,  as  much  fluid  with- 
drawn as  will  flow  naturally,  and  at  least  as  much 
serum  injected.  When  the  fluid  is  thick  and  purulent  it  is 
well  to  wash  the  cavity  with  sterile  saline  solution  to  remove 
as  much  pus  as  possible  before  the  introduction  of  the  serum. 
As  much  as  40  cubic  centimetres  may  be  injected  at  a  time, 
unless  great  restlessness  and  headache  on  the  part  of  the 
patient  shows  that  the  pressure  in  the  subarachnoid  space  is 
too  high.  The  injection  may  be  repeated  daily  or  even 
oftener  until  the  subsidence  of  symptoms. 

McKenzie  and  Martin  published  in  the  Journal  of 
Pathology  and  Bacteriology,  1908,  the  results  of  their  investi- 
gations on  the  cerebro-spinal  fluid.  They  showed  that  the 
cerebro-spinal  fluid  did  not  contain  certain  substances  which 
were  bactericidal  to  the  meningococcus  outside  the  body, 
although  such  substances  were  present  in  the  blood-serum  of 
the  same  patient.  They  accordingly  injected  into  the  sub- 
arachnoid space  serum  from  the  blood  of  other  patients  or,  in 
some  cases,  of  the  patient  himself,  to  supply  the  deficiency, 
and   the   results   seem   to   warrant   the   employment    of    such 


134  Chapter  VI IL 

•treatment,  at  least  where  there  is  difficulty  or  delay  in  the  pro- 
curing- of  a  suitable  antitoxic  serum. 

The  mere  aspiration  of  cerebro-spinal  fluid  is  at  times 
attended  by  temporary  relief  to  the  patient,  and  continuous 
drainage  of  the  subarachnoid  space  has  been  tried  in  some 
eases,  but  the  results  of  any  form  of  treatment  other  than 
serum  therapy  offer  but  little  hope  for  the  amelioration  or 
cure  of  the  disease. 

Treatment  of  Sequelae.  —  The  troublesome  muscular  weak- 
ness which  is  so  usually  present  in  cases  who  recover  from 
cerebro-spinal  meningitis  is  best  treated  by  massage  and  mild 
galvanism,  while  the  general  condition  of  the  patient  may  be 
improved  by  the  use  of  iron,  arsenic  and  strychnine.  A  good 
combination  for  older  children  and  adults  is  that  of  Ferri  et 
Amnion.  Cit.  grs.  v-x,  Liquor,  Arsenicalis  m.  ii-v,  and  Liquor. 
Strychnini  m.  iii-v,  given  thrice  daily  after  food.  In  young 
children,  nothing  is  better  than  Extract  of  Malt  and  Syr. 
Ferri  Phosph.  Co.  in  suitable  doses  according  to  the  patient's 
age.  In  cases  who  have  become  convalescent,  the  greatest 
care  must  be  taken  in  allowing  them  to  resume  work  after 
their  illness.  It  is  wise  to  forbid  a  child  to  attend  school  for 
some  six  months  after  recovery  is  apparently  complete,  and 
all  adults  who  are  engaged  in  work  involving  mental  strain 
should  have  a  corresponding  holiday  of  three  months  when  at 
all  possible.  Children  who  'show  any  signs  of  weakness  of 
mind  after  recovery  ought  to  be  kept  very  quiet  and  free  from 
strain  until  long  after  all  signs  of  intellectual  weakness  dis- 
appear. 

Epidemiology.  —  Sporadic  cases  of  epidemic  cerebro-spinal 
meningitis  are  frequently  met  with  in  many  parts  of  the 
British  Islands  and  America,  but  of  recent  years  epidemics  of 
considerable  gravity  have  occurred  in  Glasgow,  Edinburgh, 
Belfast,  the  United  States,  and  various  parts  of  Germany.  An 
epidemic  tends  to  decline  during  the  warmer  months  of  the 
year  and  to  show  exacerbation  during  the  winter  and  spring. 

Method  of  Infection.  — While  it  is  beyond  doubt  that  the 
infecting  organism  in  epidemic  cerebro-spinal  meningitis  is 
the  diplococcus  intracellularis  of  Weichselbaum,  it  is  by  no 


Epidemic  Cerebro -Spinal  Meningitis.  136 

means  so  certain  how  this  organism  gains  entry  into  the 
human  body,  and  how  infection  is  conveyed  from  an  infected 
person  to  another.  It  is  probable  that  the  organism  enters 
by  the  nasal  passages  and  tonsils,  but  study  of  the  throats  of 
patients  suffering  from  epidemic  cerebro-spinal  meningitis 
has  not  revealed  the  presence  of  the  organism,  and  it  is  quite 
possible  that  the  disease  is  carried  from  person  to  person  by 
people  who  are  not  yet  themselves  the  victims  of  the  disease 
and  may  never  become  so,  whose  nasal  and  buccal  discharges 
may  contain  the  organism  in  abundance,  but  who  are  them- 
selves apparently  healthy. 

In  studying  the  period  of  incubation  of  cerebro-spinal 
meningitis  one  is  struck  by  the  fact  that  while  two  members 
of  a  household  may  fall  ill  within  twenty-four  hours, 
other  members  of  the  household  may  escape  entirely, 
indicating  rather  that  the  two  who  were  attacked  by  the 
disease  had  been  infected  from  a  common  source,  than 
that  one  took  the  disease  from  the  other.  The  disease  is  not 
easily  transmitted  from  the  sick  person  to  those  surrounding 
him,  as  is  shown  by  the  fact  that  it  is  nursed  with  safety  in 
the  wards  of  general  hospitals,  but  it  seems  likely  that  in  the 
dirt  and  dust  of  houses,  in  unclean  streets  and  back  courts,  the 
infecting  organism  may  flourish  and  spread  the  disease,  in 
some  instances  very  widely. 

Period  of  Infectivity. —  A  patient  who  has  suffered  from 
epidemic  cerebro-spinal  meningitis  is  probably  not  infectious 
beyond  the  establishment  of  convalescence,  and  it  is  safe  to 
allow  him  to  mix  with  his  fellows  as  soon  as  his  strength  per- 
mits him  to  be  up  and  doing. 

Death- Rate. — The  death-rate  has  varied  very  much  in 
different  epidemics.  In  certain  extremely  limited  outbreaks 
it  has  been  recorded  as  between  4  per  cent,  and  27  per  cent., 
but  in  larger  epidemics  it  has  varied  between  41  per  cent,  and 
75  per  cent.  During  the  Glasgow  epidemic  between  May, 
1906,  and  May,  1908,  the  death-rate  was  74.8  per  cent.,  one 
oi  the  highest  recorded. 

Home  Prophylaxis. —  Beyond  the  general  precautions  taken 
in  the  isolation  and  care  of  patients  suffering  from  any 
one  of  the  infectious  fevers  as  indicated  in  the  introductory 


136  diaper  VIII. 

chapter,  little  ueed  be  done.  It  is  the  practice  of  many 
physicians  to  recommend  the  daily  irrigation  of  the  nasal 
passages  with  a  solution  of  sodium  salicylate  in  water,  grs.  x 
to  the  ounce,  and  the  washing  of  the  throat  with  the  same 
solution  night  and  morning  during  such  times  as  the  disease 
may  be  prevalent,  and  there  is  much  to  be  said  in  favour  of 
this  practice  among  dwellers  in  towns,  where  a  little  chronic 
inflammation  of  nose  and  throat  is  so  common,  and  the  defen- 
sive power  of  the  tonsils  and  nasal  mucous  membrane  thereby 
impaired.  The  general  health  of  all  children  during  an 
epidemic  should  be  very  strictly  attended  to. 

Public  Health  Administration. — All  cases  occurring  in 
insanitary  districts  should  be  reriioved'  to  hospital,  and  the 
houses  in  which  cases  have  occurred  must  be  thoroughly  dis- 
infected either  on  the  removal  of  the  cases  to  hospital  or  on 
their  convalescence  if  nursed  at  home.  All  bedding,  clothing 
and  furniture  which  has  been  in  contact  with  the  patient 
should  be  dealt  with  either  by  steam  or  by  formalin  solution, 
the  walls  of  the  house,  the  floors,  lobbies  and  back  yards  con- 
nected with  the  house  should  be  washed  with  formalin,  and 
all  ashpits  and  ashbuckets  should  be  cleaned  with  chloride  of 
lime  solution.  In  view  of  the  possibility  of  the  disease  being 
spread  by  expectoration,  notices  intimating  this  fact  ought  to 
be  posted  in  districts  where  the  disease  is  occurring,  and  the 
streets  and  pavements,  public  stairs  and  entries  should  be 
washed  at  least  once  a  day  with  water  charged  with  perman- 
ganate of  potash  or  some  other  suitable  disinfectant.  Faulty 
drainage  systems  must  be  corrected  and  the  necessity  for 
public  and  personal  cleanliness  insisted  on. 


(   137  ) 


Chapter  IX. 

ANTHRAX. 

Synonyms.  —  Splenic      Fever ;      Malignant     Pustule ; 
Woolsorters'   Disease. 

Fr.:      Cliarbon;    Mai    de   Eate. 
Ger.  :      Milzbrand. 

Definition.  —  An  acute  infectious  fever,  characterised 
usually  by  an  external  lesion  of  skin  or  mucous  membrane^ 
and  possibly  a  subsequent  generalised  blood  infection  with  en- 
largement of  the  spleen,  but  sometimes  primarily  septicsemic 
without  visible  external  lesion.  It  is  caused  by  a  micro- 
organism, the  Bacillus  Anthracis,  first  described  as  conveying 
the  specific  infection  of  the  disease  by  Davaine,  in  1863.  The 
name  Bacillus  Anthracis  was  given  to  it  by  Cohn,  and  the  fact 
that  it  contained  spores  was  first  demonstrated  by  Koch. 

Rash. — IN"o  rash  has  been  described  as  typical  of  the 
disease. 

Incubation  Period. — -This  is,  as  a  rule,  only  possible  of 
estimation  when  the  disease  begins  with  a  local  affection  of 
skin  or  mucous  membrane,  and  even  then  may  be  difficult  to 
determine  with  any  degree  of  accuracy.  It  is  usual  to  say 
that  the  incubation-period  may  vary  from  a  few  hours  to  some 
ten  days. 

Clinical  Types.  —  The  three  forms  in  which  the  disease  is 
met  with  commonly  in  man  are  malignant  pustule,  gastro-in- 
testinal  anthrax,  and  pulmonary  anthrax. 

Malignant  Pustule,  the  charbon  of  French  writers,  ap- 
pears as  a  vesicle  set  in  a  browny  and  inflamed  base,  usually 
produced  by  the  inoculation  of  some  scratch  or  slight  wound 
of  the  skin  or  mucous  membrane,  and  is  situated  on  the  face. 


138  Cha'pter  IX. 

angle  of  the  mouth,  lip,  buccal  mucous  membrane,  the  neck, 
liand  or  forearm  or  any  exposed  part.  A  slight  pricking  and 
burning  sensation  is  first  felt  by  the  patient  in  the  infected 
part  and  a  papule  soon  appears  on  which  forms  a  clear  vesicle, 
sometimes  of  considerable  size.  The  vesicle  ruptures  and 
dries  up,  forming  a  dark  almost  black  scab.  Round  this  cen- 
tral scab  a  ring  of  closely-set  vesicles  frequently  forms.  The 
base  of  the  vesicles  becomes  dark  and  indurated,  and  a  deep 
red  or  purple  areola  forms  round  it,  while  a  brawny  oedema 
quickly  spreads  in  the  adjoining  tissues.  Sometimes  there  is 
marked  inflammation  of  the  lymph  channels,  and  the  neigh- 
bouring lymphatic  glands  may  become  enlarged  and  tender. 
The  time  elapsing  between  the  appearance  of  the  vesicle  and 
the  formation  of  the  typical  pustule  with  its  dark  centre,  hard 
base,  deep  red  areola  and  surrounding  cedema  is  usually 
about  two  days,  and  during  this  time  the  general  health  of  the 
patient  may  not  be  affected,  save  by  a  feeling  of  slight 
malaise.  At  the  end  of  that  time,  however,  the  temperature 
rises,  and  the  patient  suffers  from  headache  and  varying 
degrees  of  prostration,  pain  in  the  limbs  and  sweating. 
Delirium  may  be  present  and  death  from  an  acute  septicaemia 
with  collapse  may  occur  about  the  fifth  to  eighth  day  of  ill- 
ness. In  other  cases  a  spread  of  the  infection  to  the  lungs, 
intestine  or  brain  takes  place,  and  the  patient  may  die  with 
the  signs  of  a  rapid  pneumonia,  violent  abdominal  pain,  diarr- 
hoea, and  vomiting,  or  the  symptoms  of  serious  cerebral 
trouble — headache,  delirium,  restlessness  and  ultimately  coma. 
As  the  symptoms  become  general  the  spleen  usually  enlarges 
so  that  it  is  palpable  below  the  costal  margins. 

In  rare  instances  the  pustule  proceeds  to  spontaneous 
cure — the  central  part  sloughs  out,  the  surrounding  indura- 
iion  disappears,  and  the  ulcer  which  remains  heals  somewhat 
slowly.  But  in  the  great  majority  of  cases  where  the  pus- 
tule is  allowed  to  develop  without  surgical  interference,  symp- 
toms of  general  septicsemia  supervene  and  the  patient  dies. 

Intestinal  anthrax  is  a  rare  condition,  even  when  it  fol- 
lows on  a  malignant  pustule,  and  is  practically  invariably 
fatal.  It  is  not  likely  to  be  diagnosed  during  life,  as  its 
symptoans  are  simply  those  of  a  profound  gastro-enteritis  with 


Anthrax.  139 

marked  general  symptoms  of  toxaemia.  Vomiting  and  diarr- 
hcea  set  in  after  a  short  time  of  malaise,  headache,  anorexia, 
and  pain  in  the  back  and  limbs.  The  evacuations  frequently 
contain  blood.  Dyspnoea  and  cyanosis  make  their  appear- 
ance early  and  the  jDatient  may  be  eitlier  mildly  delirious  (jr 
stuporose.  Convulsions  may  occur,  of  an  epileptiform  type, 
and  tliere  may  be  some  tetanoid  spasm  of  the  arms.  Fever 
may  not  be  high,  and  death  is  ushered  in  by  extreme  collapse. 
The  duration  of  this  type  of  the  disease  is  from  a  few  hours  to 
about  a  week. 

Pulmonary  Anthrax,  like  the  intestinal  form  of  the  dis- 
ease, may  occur  either  as  a  primary  condition  or  as  the  sequel 
of  a  malignant  pustule.  It  is  not  quite  so  fatal  as  the  intestinal 
form.  The  symptoms  of  onset  are  prostration  and  a  sense  of 
great  oppression  in  the  chest.  Respiration  is  not  com- 
monly rapid,  but  is  laboured  and  difficult.  Cough  is  present, 
and  may  or  may  not  be  accompanied  by  expectoration,  which 
is  usually  profuse  and  blood-stained.  Physical  examination 
of  the  lungs  reveals  little  but  generalised  rhonchi,  and  some 
moist  crepitation  at  the  bases.  The  face  is  cyanosed,  and  the 
extremities  are  usually  cold  and  blue.  The  temperature  is 
elevated  in  the  rectum,  although  in  the  axilla  or  groin  it  may 
be  subnormal.  The  pulse  is  rapid,  of  low  pressure,  and  mar 
be  markedly  irregular.  Death  may  be  preceded  by  delirium  or 
coma,  or  the  patient  may  be  quite  conscious  to  the  end,  which 
comes  suddenly  with  rapid  cardiac  failure.  Such  cases  are 
usually  fatal  within  five  days,  sometimes  within  the  first 
twenty-four  hours,  and  if  a  patient  survives  for  a  week,  it  is 
said  that  he  has  a  cliance  of  recovery. 

Other  forms  are  those  where  the  symptoms  are 
entirely  cerebro-spinal,  and  the  patient  may  suffer  from 
what  appears  to  be  acute  meningitis,  with  vomiting, 
headache,  irregular  respiration  and  pulse-rate,  delirium  and 
headache,  or  coma,  sometimes  a  little  retraction  of  the  head 
and  even  episthotonos.  In  another  class  of  case  the  patient 
may  present  no  symptoms  referable  to  any  organ,  and  merely 
show  signs  of  a  profound  toxtemia  with  fever  and  delirium  or 
coma.  In  this  last  class  of  case  the  spleen  may  be  enlarged. 
Such  irregular  forms  of  the  disease  are  always  fatal. 


140  Cha'pter  IX. 

Diagnosis. — There  is  little  difficulty  in  the  diagnosis  of 
a  typical  malignant  pustule  where  a  central  scab  and  ring  of 
vesicles  are  present  set  in  a  hard  reddened  base  with  sur- 
rounding brawny  oedema,  but  even  when  this  is  present  it  is 
well  to  try  to  establish  the  diagnosis  by  a  search  for  the 
bacillus  of  anthrax.  As  a  rule  it  is  easily  recovered  from  the 
ring  of  vesicles  or  the  base  of  the  pustule  by  incision,  and  the 
making  of  a  smear-preparation  of  the  exuding  fluid,  but  if  the 
pustule  has  sloughed  considerably  it  is  often  impossible  to 
obtain  recognisable  forms  of  the  organism.  The  appearance 
of  the  organism  is  very  typical — long  thick  bacilli  with  rather 
squared  ends  showing  in  many  instances  evidence  of  spore- 
formation  in  the  shape  of  clear  oval  spaces  interrupting  the 
stained  protoplasm  of  the  organism.  In  cases  where  much 
sloughing  of  the  pustule  has  taken  place  the  bacilli  may  be 
unrecognisable  from  degeneration  and  the  only  indication  of 
the  infecting  organism  may  be  the  presence  of  ill-stained  oval 
bodies  suggestive  of  spores.  Under  these  circumstances  it  is 
necessary  to  make  a  culture  from  the  remains  of  the  vesicles 
and  from  the  reddened  area  after  incision,  and  if  the  organism 
or  its  spores  are  present  a  growth  should  be  obtainable  on 
agar  after  twenty-four  hours'  incubation  at  37°  C.  The 
bacillus  stains  well  with  ordinary  basic  anilin  dyes,  and  gen- 
tian violet  is  a  convenient  and  rapid  stain.  In  cases  of 
primary  cerebral,  septicsemic,  intestinal  and  pulmonary  an- 
thrax the  recovery  of  the  bacillus  is  the  only  means  of  arriving 
at  a  correct  diagnosis.  In  the  majority  of  such  cases  the  bac- 
illus may  be  recovered  from  the  peripheral  blood-stream,  either 
by  the  direct  examination  of  smear-preparations,  by  incubation 
of  5  or  10  cubic  centimetres  of  blood  in  peptone  bouillon  at  37° 
C,  or  by  injecting  a  few  cubic  centimetres  of  blood  into  some 
susceptible  animal  such  as  a  rabbit  or  guinea-pig. 

The  bacillus  can  usually  be  recovered  from  the  spleen  by 
puncture  in  cases  where  the  symptoms  are  general  and  severe, 
but  as  the  anthrax  spleen  is  soft,  this  is  not  a  practice  to  be 
recommended.  Puncture  of  the  spleen  by  a  Pasteur's  pipette 
is  a  method  useful  for  the  recovery  of  the  bacillus  M^hen  a 
patient  has  died  with  symptoms  resembling  a  general  infec- 
tion with  anthrax,  and  under  circumstances  where  there  was  a 
possibility  of  such  infection  occurring. 


Anthrax.  141 

In  arriving  at  a  presumptive  diagnosis  of  anthrax,  the 
occupation  of  the  patient  must  always  be  considered,  remem- 
bering that  butchers,  cattlemen,  shepherds,  wool-sorters  and 
workers  in  horse-hair  are  those  most  likely  to  be  exposed  to 
infection  by  the  B.  Anthracis. 

Treatment. — Where  there  is  any  visible  external  lesion 
it  should  be  freely  excised,  and  the  resulting  wound  swabbed 
with  pure  carbolic  acid  or  a  strong  solution  of  caustic  potash, 
or  the  actual  cauterj^  may  be  applied  freely  to  the  raw  sur- 
faces. In  some  countries  the  malignant  pustule  is  destroyed 
by  the  actual  cautery  or  caustic  potash  without  incision.  The 
practice  of  filling  the  wound  with  powdered  ipecacuanha  after 
excision  of  the  pustule  has  been  attended  with  good  results. 
The  success  of  surgical  treatment  depends  largely  on  the  stage 
at  which  the  disease  is  encountered.  If  the  pustule  is  in  an 
early  stage,  before  there  are  any  constitutional  symptoms,  ex- 
cision offers  considerable  hope  for  the  patient's  recovery, 
especially  if  the  pustule  be  -situated  on  the  hand,  arm  or  leg. 
When  it  is  situated  on  the  neck,  there  is  more  chance  of  the 
early  involvement  of  lymphatic  glands  than  if  it  were  situated 
at  more  distant  parts,  and  excision  offers  less  hope  of  cure, 
while  there  is  always  danger  of  the  oedema  of  the  surrounding 
tissues  causing  suffocation  either  from  pressure  on  the  trachea, 
or  from  actual  spread  to  the  epiglottis  or  larynx.  If  it  be 
situated  on  the  face,  angle  of  the  mouth,  lip,  or  buccal  mucous 
membrane,  the  chance  of  preventing  a  general  infection  by 
excision  of  the  local  focus  is  much  more  remote,  indeed,  in 
certain  situations,  e.g.,  the  buccal  mucous  membrane  or  the 
eyelid,  excision  is  extremely  difficult.  When  the  infection  is 
general,  whether  primarily  so  or  secondary  to  a  malignant 
pustule,  the  patient  generally  dies,  although  certain  cases 
of  the  pulmonary  variety  who  have  survived  the  first  week  of 
illness  have  been  known  to  recover.  Beyond  surgical  inter- 
ference, where  serum  is  not  used,  treatment  must  be  purely 
palliative  and  consists  in  relieving  pain  and  subduing  rest- 
lessness by  the  use  of  morphine  hypodermically  or  some  pre- 
paration of  opium  by  the  mouth,  and  in  stimulating  the 
patient  when  there  is  any  indication  of  collapse  or  cardiac 
failure  by  the  use  of  alcohol  and  hot  applications  on  the 
heart.       Where     siffus     of     cardiac     failure    have     declared 


142  Chapter  IX. 

themselves  tlie  'coiulitioii  is  so  liojDeless  tli'at  treatment  .*s 
carried  out  rather  from  a  sense  of  diity  than  from  any  hope 
of  good  result. 

Within  recent  j^ears,,  however,  Sclavo  of  Siena  has  pre- 
pared- an  anti-anthrax  serum  obtained  by  immunising  asses. 
This  serum  is  not  as  accurately  standardised  as  antidiph- 
theritic  serum,  but  its  immunising  powers  are  tested  on  rabbits 
before  it  is  put  into  circulation.  Sclavo  uses  the  serum 
alone  in  his  treatment  of  anthrax  cases,  and  this  is  the  more 
general  practice  in  Italy,  but  in  England  it  has  been  used  in 
combination  with  local  treatment  of  the  pustule.  The  dosage 
should  be  large,  50  cubic  centimetres  as  a  first  dose,  and  40 
cubic  centimetres  on  each  succeeding  day  for  two  or  three 
days,  until  the  symptoms  have  abated.  Sometimes  a  single 
dose  is  sufficient,  and  the  number  of  doses  necessary  will  de- 
pend on  the  severity  of  the  case.  It  is  of  the  utmost  import- 
ance that  this  treatment  should  be  begun  as  early  in  the 
course  of  the  disease  as  possible.  The  results  of  serum  therapy 
are  very  encouraging.  Legge's  views  are  to  be  found  in  the 
report  of  the  Milroy  lecture,  1905,  in  the  British  Medical 
Journal  for  March  18th  of  tht^t  year.  He  analyses  67  cases,  of 
which  56  were  treated  with  serum  alone,  and  out  of  these  67 
cases  only  two  died.  In  1903  Sclavo  reported  his  results  in 
167  cases  when  he  had  a  case-mortality  of  only  6.09  per  cent., 
at  a  time  when  the  mortality  in  the  rest  of  Italy  was  24.1  per 
cent.  The  serum  seems  to  be  quite  innocuous  even  in  large 
doses,  and  is  well  borne  when  injected  into  a  vein.  From  the 
cases  reported  it  would  seem  that  no  case  of  moderate  severity 
need  die  if  serum  is  used  in  the  early  stages,  while  many  cases 
which  looked  hopeless  were  cured  by  the  use  of  the  serum, 
even  when  the  situation  of  the  pustule  made  excision  impos- 
sible. One  of  the  advantages  of  the  early  use  of  serum  is  that 
it  prevents  loss  of  tissue  from  sloughing  of  the  pustule  in  a 
marked  degree.  In  the  intestinal,  pulmonary  and  cerebral 
types  of  the  disease,  or  in  any  case  where  the  bacilli  are  found 
in  the  blood  stream  or  which  seems  of  considerable  gravity, 
the  serum  should  be  giA^en  intravenously,  and,  indeed,  intra- 
venous administration  of  serum  is  the  only  form  of  treatment 
which  oifers  the  slightest  hope  of  the  cure  of  such  cases. 


Anthrax.  143 

When  patients  suifering  from  malignant  pustule  Lave 
been  treated  with  the  serum,  their  convalescence  is  usually 
strikingly  rapid  and  complete. 

Epidemiology. — Anthrax  is  primarily  a  disease  of  liorses, 
sheep,  cattle,  deer  and  goats,  and  is  met  with  practically  in 
every  part  of  the  world.  In  the  United  States  and  Australia  it 
is  rare,  and  while  it  is  comparatively  common  in  Great  Britain, 
it  does  not  occur  in  this  country  with  anything  like  the  same 
frequency  as  it  occurs  among  the  susceptible  animals  in 
France,  Germany,  Russia,  Italy,  Turkey,  Asia,  South  America 
and  in  some  of  the  Northern  parts  of  Africa.  Pastures  be- 
come infected  so  that  new  flocks  or  herds  arriving  there  con- 
tract the  disease,  and  may  in  their  turn  infect  other  pastures 
by  their  discharges.  The  infection  of  fields  has  been  known  to 
result  from  the  scattering  over  them  of  infective  refuse  from 
factories  or  the  carrying  of  infective  material  from  workshops 
to  them  by  floods.  Anthrax  may  be  carried  from  animal  to 
animal  by  blood-sucking  flies. 

Method  of  Infection  in  Man. —  Anthrax  is  always  trans- 
mitted to  man  by  contact,  direct  or  indirect,  with  infected 
animals.  Shepherds,  cattlemen,  butchers  and  men  employed 
in  slaughter-houses  become  infected  through  some  abrasion  o£ 
their  skin.  I  recollect  one  case  in  a  man  who,  suspecting 
tuberculosis  in  a  cow  which  had  died  mysteriously,  made  an 
opening  into  the  thorax  through  which  he  introduced  his  arm 
to  examine  the  pleura  for  nodules.  He  was  conscious  at  the 
time  that  he  grazed  his  forearm  on  a  rib,  and  a  few  days 
afterAvards  noticed  that  the  scratch  was  inflamed  and  itchy. 
A  typical  malignant  pustule  developed  which  was  removed, 
and  the  man  recovered. 

Tanners  and  woolsorters  are  frequently  infected  by  hides 
and  wool  imported  from  infected  districts.  Those  who  work 
with  horsehair  in  the  making  of  mattresses,  furniture  and 
saddles  are  also  liable  to  become  infected  from  imported 
hair.  Siberian  horse-hair  is  particularly  dangerous  in  this 
respect,  and  its  importation  is  discouraged  in  Great  Britain. 
There  is  nothing  which  shows  the  extraordinary  powers  of  re- 
sistance of  the  anthrax  spores  more  than  the  fact  that  girls 
sometimes  contract  anthrax  who  are  employed  in  the  stuffing^ 


144  Chapter  IX. 

of  mattresses  and  furniture  with  black  horse-hair  which  has 
been  previously  curled  by  heat  and  dyed  by  chemical  pro- 
cesses. Tanners,  butchers,  shepherds  and  cattlemen  com- 
monly contract  the  external  form  of  the  disease;  woolsorters 
are  more  liable  to  the  internal  forms,  from  the  inhalation  or 
swallowing  of  infective  dust,  while  workers  in  horse-hair  con- 
tract both,  the  internal  form  rather  predominating. 

There  is  no  doubt  that  sometimes  the  infection  is  conveyed 
t-o  man  by  the  bites  of  insects,  while  the  source  of  infection  in 
a  few  cases  seems  to  have  been  infected  meat  which  had  been 
eaten. 

Period  of  Infectivity. — It  is  safe  to  assume  that  when 
convalescence  is  established  there  is  no  longer  any  danger  of 
the  patient  being  infectious.  It  is  probable  that  the  bodies  of 
men  and  animals  who  have  died  of  the  disease  remain  infective 
for  a  long  time,  and  the  careless  disposal  of  these  may  help  to 
spread  the  infection. 

Death- Rate. — This  varies  greatly  with  the  types  of  the 
disease.  In  the  external  forms,  which  have  been  treated  by 
excision  or  cautery,  or  both,  the  death-rate,  when  the  pustule 
is  situated  on  the  extremities,  is  probably  between  five  and  ten 
per  cent. ;  when  it  is  situated  on  the  face  or  neck,  about  25  per 
'Cent.  Of  the  internal  forms,  the  cerebral  and  intestinal  types 
are  practically  always  fatal,  and  the  death  rate  in  the  pul- 
monary type  is  probably  between  70  and  80  per  cent. 

Home  Prophylaxis. — For  workers  among  wool  and  hair, 
butchers,  shepherds  and  tanners  it  is  of  the  greatest  import- 
ance that  the  hands  should  be  thoroughly  cleaned  after  work, 
and  the  slightest  abrasion  of  the  skin  on  the  exposed  parts  of 
the  body  should  be  treated  antiseptically  and  sealed.  Those  in 
attendance  upon  anthrax  cases  ought  to  observe  carefully  the 
same  precautions,  and  must  remember  that  the  sputum  in  the 
pulmonary  type  and  the  motions  in  the  intestinal  type  are 
probably  highly  infective,  should  be  handled  with  the  greatest 
care,  and  must  be  disposed  of  by  burning  or  by  mixing  with 
tin  equal  quantity  of  a  1  in  500  solution  of  perchloride  of  mer- 
cury or  a  strong  formalin  solution,  and  allowed  to  stand  for 
some  hours  before  being  allowed  to  pass  into  the  drains.  All 
'dressings  should  be  burnt  as  soon  as  they  are  taken  off,  and 


Anthrax.  145 

bedclothes  should  be  frequently  changed  and  immersed  in  a 
1  in  500  solution  of  perchloride  of  mercury  or  strong  solution 
of  formalin  before  being  boiled  previous  to  washing.  If  the 
patient  is  nursed  at  home  he  should  be  isolated  as  strictly  as 
possible. 

Public  Health  Administration. — When  a  case  of  anthrax 
has  occurred  in  man  the  Plonie  Office  must  be  formally  notified 
by  the  usual  certificate,  and  the  local  authority  warned  of  its 
occurrence.  The  source  of  infection  must  be  investigated, 
and  if  it  be  found  that  the  infection  has  been  introduced  by 
wool,  hair  or  hides,  the  suspected  consignment  ought  to  be 
destroyed,  the  place  from  which  they  come  notified,  and  the 
condition  of  sheep,  cattle,  and  horses  in  that  district  investi- 
gated. In  the  case  of  repeated  infected  consignments  coming 
from  the  same  district  abroad,  it  may  be  necessary  for  a  time 
to  prohibit  the  importation  of  wool,  hair  or  hides  from  that 
district.  Similarly  if  the  infection  is  due  to  diseased  cattle 
or  sheep  in  the  case  of  butchers,  workers  in  the  slaughter- 
house, and  shepherds,  the  strictest  investigation  must  be  made 
in  the  districts  from  which  the  cattle  or  sheep  come  and 
the  source  of  the  infection  removed,  whether  it  be  infected  pas- 
ture or  buildings  or  unrecognised  cases  of  anthrax  among  the 
flocks  and  herds.  If  the  infected  cattle  or  sheep  have  come 
from  abroad,  it  may  be  necessary  to  exercise  for  some  time  a 
careful  supervision  of  all  consignments  from  the  country 
which  has  supplied  the  diseased  animals,  and,  if  necessary, 
even  to  prohibit  altogether  further  consignments  from  that 
country  until  evidence  can  be  produced  that  there  is  little  or 
no  danger  of  diseased  animals  being  again  imported. 

Disinfection  of  the  houses,  bedding,  clothing  and  furni- 
ture which  have  been  used  by  a  patient  seized  with  anthrax 
should  be  thoroughly  carried  out  with  strong  formalin  solu- 
tions, and  the  walls,  floors,  stairs  and  lobbies  of  the  house 
where  the  case  has  occurred  must  be  dealt  with  in  the  same 
way.  It  is  to  be  remembered  that  although  the  bacillus  itself 
is  easily  killed,  its  spores  are  extraordinarily  resistant.  It  is 
best  that  the  bodies  of  all  cattle  and  human  beings  who  have 
died  of  anthrax  should  be  disposed  of  by  cremation. 


(    146    ) 


Chapter  X. 

GLANDERS. 

Synonyms. — Farcy,  Equinia,  Malleus. 
Fr.  :      La  Morve,  Le  Farcin. 
Ger.  :      Eotzkranklieit,  Wurmkrankheit,  Driise. 

Definition. —  An  acute  infective  disease  characterised  by 
granulomata  affecting  the  mouth  and  nares  (glanders),  and 
the  subcutaneous  and  muscular  tissues  (farcy),  caused  by  a 
specific  micro-organism,  Bacillus  IfaZ/ez, discovered  by  Schiitz 
and  Loeffler  in  1882. 

Rash.- — In  some  cases  there  is  a  more  or  less  generalised 
erythema,  and  a  papulo-pustular  eruption  is  among  the 
typical  manifestations  of  the  disease. 

Incubation  Period.  — This  is  difiicult  to  determine  accur- 
ately, and  is  probably  very  variable.  It  is  usual  to  say  that 
the  incubation  period  is  from  five  to  fifteen  days,  but  it  is 
possible  that  this  period  may  be  exceeded. 

Clinical  Types. — Glanders  in  man,  as  in  the  horse,  may 
follow  an  acute  or  chronic  course,  and  some  writers  speak  of 
acute  and  chronic  glanders,  meaning  glanders  primarily  at- 
tacking the  nose  and  the  mucous  membrane  of  the  respiratory 
tract,  and  of  acute  and  chronic  farcy — glanders  manifesting 
itself  as  nodules  in  the  subcutaneous  tissues  which  break 
down,  and  which  are  often  associated  with  enlargement  of  the 
lymph-glands  and,  possibly,  phlegmonous  inflammations. 
There  seems  little  use  to  confuse  by  the  use  of  the  term  ''farcy." 
In  nasal  cases  the  lesions  are  the  same  as  the  subcutaneous, 
rapidly  forming  granulomata  that  tend  to  break  down,  forming 
small  abscesses  and  ulcers. 


Glanders.  147 

Acute  Glanders. — The  symptoma  of  invasion  are  those 
common  to  any  acute  febrile  condition,  and  the  patient  com- 
plains of  headache,  general  malaise,  pains  in  the  back  and 
limbs,  anorexia  and  nausea.  Shortly  after  these  premonitory 
symptoms,  the  temperature  is  raised,  but  it  is  not  until  some 
days  later  that  the  typical  lesions  make  their  appearance,  and 
if  these  appear  first  in  the  nose,  it  may  be  some  time  before  a 
diagnosis  is  arrived  at.  The  mucous  membrane  of  the  nose 
becomes  congested  and  invaded  by  nodules  and  the  whole 
nose  swells.  The  nodules  break  down  rapidly  and  a  purulent 
discharge  comes  from  the  nostrils.  At  the  same  time  it  is 
common  to  have  an  eruption  of  papules  round  the  nose  and 
mouth  and  over  the  face  generally  which  quickly  become  pus- 
tular, after  which  they  burst,  leaving  little  superficial  ulcers, 
or  dry  up  to  form  scabs.  Small  patches  of  a  purplish  erythema 
are  also  seen,  and  on  palpation  they  are  found  to  overlie  a 
small  firm  nodule,  like  an  erythema  nodosum,  which  is  tender. 
The  nodule  enlarges,  softens  and  breaks  down,  while  the  skin 
often  shows  bullae  which  burst  as  the  nodule  softens,  and  with 
the  breaking  down  of  the  nodule  a  ragged  ulcer  is  formed. 
Similar  nodules  form  deep  in  the  muscles  and  also  soften 
and  break  down  while  the  skin  over  them  inflames,  gives  way, 
and  an  ulcer  forms.  Haemorrhages  may  occur  into  or  "around 
the  nodules.  A  subacute  pneumonia  is  frequently  met  with, 
and  in  some  cases,  after  a  short  period  of  malaise,  the  initial 
illness  may  closely  resemble  an  attack  of  acute  lobar  pneu- 
monia, and  it  is  not  until  the  development  of  cutaneous 
lesions,  either  nodules  or  papules,  some  days  later,  that  the 
true  nature  of  the  infection  may  be  apparent. 

In  certain  cases  the  formation  of  nodules  may  be  associ- 
ated with  all  the  signs  and  symptoms  in  neighbouring  large 
joints  of  a  more  or  less  acute  arthritis — pain,  tenderness  and 
swelling  round  the  joint  and  fluid  effusion  into  the  joint- 
cavity.  The  fluid  is  at  first  clear  and  serous,  but  after  some 
days  it  becomes  purulent.  In  one  case  mentioned  by  Goodall, 
suppuration  did  not  take  place  for  thirteen  or  fourteen  davs. 
Occasionally  a  subperiosteal  abscess  may  form,  either  alone 
or  in  connection  with  a  suppurating  joint.  Sometimes  the 
first    obvious    lesion     appears     at    what    was    probably    the 


148  Chapter  X. 

site  of  inoculation  in  the  skin.  In  such  cases  a  phlegmonous 
inflammation  arises  at  the  probable  site  of  inoculation  and 
little  swellings  appear  along  the  course  of  the  lymphatics. 
These  suppurate  and  there  is  also  enlargement  and  possibly 
suppuration  of  the  lymphatic  glands.  Pain  and  swelling  of 
neighbouring  joints  occur  but  superficial  lesions  of  the  skin 
are  not  common. 

The  symptoms,  beyond  the  symptoms  of  invasion,  depend 
absolutely  on  the  situation  in  which  the  first  nodules  appear. 
If  in  the  nose,  the  disease  will  at  first  resemble  an  extra- 
ordinarily acute  nasal  catarrh;  if  in  the  muscles,  the  associ- 
ated pain  may  resemble  acute  rheumatism;  if  in  the  lung,  an 
attack  of  acute  lobar  pneumonia. 

Chronic  Glanders. — The  chronic  type  of  glanders  pre- 
sents symptoms  and  lesions  similar  to  those  met  with  in  the 
acute  type,  but  the  course  of  the  disease  is  slow  and  its  mani- 
festations less  active.  The  period  of  invasion  is  prolonged, 
and  a  patient  may  suffer  for  weeks  from  malaise,  headache, 
loss  of  appetite,  slight  fever,  nasal  catarrh,  and  pains  in  joints 
and  muscles  before  the  appearance  of  subcutaneous  or  intra- 
muscular nodules.  On  examination,  the  nasal  catarrh  may 
be  found  to  be  associated  with  some  ulceration  of  the  mucous- 
membrane,  and  an  indolent  ulceration  may  be  present  in  the 
mouth.  The  subcutaneous  and  intramuscular  nodules  slowly 
soften  and  the  more  superficial  form  ragged,  sluggish  ulcers, 
while  the  deeper  discharge  through  unhealthy  sinuses.  The 
ulcers  and  sinuses  tend  to  heal  and  break  down  again,  and  this 
tendency  is  a  notable  feature  in  the  disease.  Cellulitis  may 
result  from  infection  of  the  chronic  glanders  sores  by  pyo- 
genic organisms.  It  is  to  be  remembered  that,  although  the 
disease  may  be  running  a  chronic  course,  an  acute  exacerba- 
tion raaj  occur  at  any  moment. 

In  some  cases  the  disease  may  appear  onlj^  as  a  chronic  in- 
flammation and  ulceration  of  the  larynx,  trachea  and  bronchi, 
the  patient  suffering  from  hoarseness  and  cough,  and  a  diag- 
nosis of  glanders  may  not  be  made  unless  an  acute  exacerbation 
of  the  disease  occurs  with  the  formation  of  the  typical  nodules 
in  the  skin  and  subcutaneous  or  muscular  tissues. 


Glanders.  149 

Diagnosis. — Before  the  development  of  the  typical 
lesions,  glanders  lias  been  mistaken  for  smalljjoa,  when  the 
papular  and  pustular  eruption  on  the  face  and  body  has  been 
unusually  profuse ;  for  enteric  fever  when  a  prolonged  pyrexia 
and  mild  pulmonary  affection  have  been  the  chief  features  in 
the  early  part  of  the  attack;  for  acute  lobar  'pneumonia  where 
consolidation  and  abscess  formation  in  the  lung  with  an  her- 
petiform  eruption  about  the  nose  and  mouth  have  been  the 
obvious  lesions;  and  for  acute  rheuw.atisw,  in  those  cases 
where  pain  in  muscles  and  pain,  swelling  and  effusion  in  a 
joint  have  preceded  the  appearance  of  deeply  seated  nodules 
in  a  limb.  Where,  as  sometimes  happens,  the  fever  is 
markedly  remittent  or  intermittent,  the  diagnosis  of  some 
obscure  septica^inia  or  pyoe-Tnia  has  been  made,  and  in  cases 
where  there  is,  at  the  beginning  of  an  attack,  a  prolonged 
pyrexia  without  any  obvious  lesions,  the  case  is  frequently 
mistaken  for  enteric  fever  or  influenza.  In  those  acute  cases 
which  present  marked  signs  of  nasal  ulceration  the  diagnosis  is 
not  usually  difficult,  as  there  is  no  other  disease  which  pro- 
duces such  marked  and  rapid  swelling  of  the  whole  nose  and 
is  associated  with  a  papular  eruption  which  rapidly  becomes 
pustular,  but  it  is  to  be  remembered  that  marked  nasal  impli- 
cation is  not  very  common.  Similarly  when  the  primary 
lesion  is  in  the  mouth,  its  characters  and  its  association  with 
a  papulo-pustular  eruption  on  the  face,  make  it  unlikely  to  be 
mistaken  for  anything  else.  But  both  the  papular  stage  and 
the  pustular  stage  of  the  eruption  may  closely  simulate  small- 
pox, although  the  course  of  the  disease  and  the  eruption  are 
very  different  in  the  two  infections.  In  glanders,  the  erup- 
tion appears  only  after  many  days  of  premionitory  symptoms, 
and  is  never  vesicular,  w^hile  in  smallpox  the  papules  appear 
on  the  third  day  of  illness,  and  run  through  a  definite  course 
as  vesicles  before  becoming  pustules.  In  the  type  of  glanders 
which  may  give  rise  to  a  diagnosis  of  acute  rheumatism  it  is 
uncommon  to  find  more  than  one  joint  affected,  quite  unlike 
the  implication  of  one  joint  after  another  which  is  the  rule  in 
acute  rheumatism,  and  if  effusion  into  a  joint  does  occur,  it 
is  almost  certain  to  become  purulent.  The  typical  lesions  in 
glanders,  nodules  which  break  down  and  form  abscesses  in  the 


150  Chapter  X. 

subcutaneous  tissue  and  in  the  muscles,  serve  to  differentiate 
the  disease  from  other  conditions,  even  from  enteric  fever, 
where  it  is  very  unusual  to  have  abscess  formation  until  well 
on  in  the  third  week  of  illness,  and  in  which  abscess-forma- 
tion is  rather  inter-  than  intra-muscular.  Widal's  test  and 
the  making  of  cultures  from  the  blood  will  also  help  to 
differentiate  the  disease. 

The  occupation  of  the  patient  is  a  valuable  aid  to  a  pre- 
sumptive diagnosis  of  glanders.  It  always  occurs  among 
tliose  who  are  associated  with  horses,  and  it  is  well  to  suspect 
this  disease  in  any  one  whose  occupation  or  tastes  bring  him 
into  close  contact  with  the  horse  and  who  has  developed  an  acute 
suppurative  condition  or  an  obscure  febrile  disorder  whether 
associated  or  not  with  eruptive  nasal  catarrh,  or  the  formation 
of  cutaneous  or  intra-muscular  nodules. 

The  ultimate  diagnosis  must  be  inade  on  the  recovery  of 
the  Bacillus  Mallei  from  the  lesions.  The  bacillus  is  short, 
straight  or  slightly  curved,  having  rounded  ends.  It  is  best 
stained  by  carbolthionin-blue.  It  grows  rapidly  in  any  or- 
dinary medium  and  is  a  facultative  anserobe.  In  chronic 
cases  of  the  nasal  type,  the  bacillus  may  not  grow  on  culture- 
media  inoculated  from  the  secretions  of  the  nose,  and  it  may 
be  necessary  to  make  an  emulsion  of  the  secretion  in  sterile 
salt-solution  and  inject  it  into  the  peritoneal  cavity  of  a  male 
guinea-pig,  when,  if  the  bacillus  is  present,  an  inflammation 
of  the  testicles  and  skin  of  the  scrotum  occurs,  and  death 
results  in  two  or  three  weeks,  with  widespread  glanders  in  the 
viscera. 

Malleiu,  a  fluid  containing  the  active  toxins  of  the 
bacillus,  may  be  used  as  a  test  in  obscure  chronic  cases,  in  the 
same  way  as  tuberculin.  If  the  patient  suffers  from  glanders 
both  a  local  and  general  reaction  follow  on  the  injection,  if 
he  is  not  suffering  from  glanders,  no  reaction  follows. 

Complications. — The  rarer  manifestations  of  the  disease, 
such  as  subperiosteal  abscess,  pericarditis,  and  meningitis, 
may  perhaps  be  best  described  as  complications.  The  other 
complications  are  of  the  pysemic  and  septicaemic  kind  which 
may    arise    from    a    secondary    infection    of    the  lesions    by 


Glanderx.  151 

pyogenic  organisms — cellulitis,  lymphangitis,  suppuration  of 
lymphatic  glands,  pyogenic  bronclio-pneumonia,  &c. 

Sequelae. —  In  the  few  cases  who  recover  no  notable 
sequelae  as  a  rule  occur  except  a  prolonged  physical  and  psy- 
chical enfeeblement  due  to  the  long  and  severe  febrile  illness. 

Treatment. — The  treatment  of  acute  glanders  in  the 
human  subject  is  very  hopeless,  since  the  signs  which  make 
the  diagnosis  possible  do  not  appear  until  the  disease  has  been 
active  for  many  days.  If  a  wound  has  been  infected,  it 
should  be  treated  with  the  actual  cautery  as  early  as  possible. 
Lugol's  solution  should  be  injected  into  the  pustules  and 
nodules,  and  some  40-50  cubic  centimetres  of  bullock's  serum 
may  be  injected  subcutaneously  or  intravenously,  on  the 
ground  that  cattle,  being  immune  to  glanders,  may  have  in 
their  serum  a  substance  naturally  antagonistic  to  the 
bacillus  mallei  and  its  products.  The  general  strength  of  the 
patient  should  be  maintained  by  rest,  careful  feeding  and 
stimulation,  but  the  outlook  is  bad,  and  very  few  cases  re- 
cover from  this  form  of  the  disease. 

In  chronic  glanders  the  skin  lesions  should  be  scraped, 
washed  with  Lugol's  solution  and  packed  with  iodoform 
gauze.  The  nose  should  be  washed  out  with  a  solution  of 
boric  acid,  borax  or  permanganate  of  potash,  and  every  visible 
ulcer  ought  to  be  touched  with  lactic  acid  or  chloride  of  zinc. 
Repeated  "  malleinisation"  may  be  practised  as  recommended 
by  Babes,  aVtb — t\^^'^  ^^  ^  cubic  centimetre  being  in- 
jected every  two  or  three  days  for  some  months  if 
necessary.  The  patient  must  be  put  under  the  best  possible 
surroundings  as  regards  hygiene,  rest  and  food. 

Diet. — In  acute  glanders  the  patient  must  be  given  a 
fluid  and  semi-solid  diet  of  as  high  a  nutritive  value  as  pos- 
sible, and  stimulants  may  be  given  freely. 

In  chronic  glanders  the  diet  should  be  liberal  and  sus- 
taining, including  eggs,  fish,  lightly  cooked  steak  or  chop, 
and  roasted  or  boiled  beef  and  mutton.  Stout  is  a  useful  form 
of  stimulant  in  such  cases. 

Epidemiology. — Glanders  is  primarily  a  disease  of  the 
horse,  and  is  met  with  wherever  horses  are  used,  but  especi- 
ally in  the  larger  towns.     In  the  British  Islands  it  appears 


162  Chapter  X. 

among  the  horses  of  London  and  Glasgow  more  than  in  any 
other  districts.  It  is,  however,  a  rare  disease  in  man,  and 
very  few  deaths  are  reported  annually  in  the  United  Kingdom 
from  this  canse.  It  has  been  acquired  in  the  laboratory,  and 
may  be  communicated  by  one  human  being  to  another.  It 
affects  almost  exclusively  those  who  work  among  horses.  The 
cases  which  appear  are  always  isolated,  and  the  disease  never 
becomes  epidemic  in  man. 

Method  of  Infection. — It  is  probable  that  in  many  cases 
glanders  is  acquired  through  some  small  abrasion  of  the  skin 
or  mucous  membrane,  but  it  may  also  be  acquired  by  the 
ingestion  of  infective  material.  It  may  be  conveyed  directly 
from  tli€  horse  to  man  and  from  man  to  man,  and  also  through 
the  medium  of  stable  litter. 

Period  of  Infectivity. — In  acute  glanders  the  few  cases 
which  recover  are  probably  not  infectious  after  convalescence 
is  thoroughly  established,  but  in  clironic  glanders  it  is  diffi- 
cult to  give  a  definite  limit  for  the  period  of  infectivity.  It 
is,  however,  reasonable  to  suppose  that  after  the  complete 
healing  of  every  accessible  lesion  the  patient  is  no  longer  a 
danger  to  the  community. 

Death-Rate. — Upwards  of  90  per  cent,  of  all  persons 
attacked  with  acute  glanders  die,  and  even  in  the  chronic  form 
of  the  disease  the  mortality  is  probably  well  over  50  per  cent. 
It  is  usual  to  give  a  more  favourable  prognosis  where  the 
disease  is  limited  in  distribution,  as  when  only  the  skin  or  one 
extremity  happens  to  be  affected.  "When  the  external  lesions 
tend  to  heal  the  outlook  is  also  more  favourable. 

Home  Prophylaxis. — Cases  of  glanders  whether  acute  or 
chronic  should  be  strictly  isolated  and  the  usual  precautions 
taken  with  body-clothing,  bed-clothes  and  discharges.  The 
local  authority  must  be  advised  of  the  occurrence  of  any  case. 
Those  in  attendance  on  the  patient  ought  to  be  extremely 
careful  to  seal  any  abrasions  on  the  skin  which  happen  to  be 
present,  and  ought  to  wash  the  hands  and  clean  the  nails  most 
scrupulously  after  touching  the  patient.  All  those  who  work 
in  stables  ought  to  watch  horses  carefully  for  any  signs  sus- 
picious of  glanders  and  on  the  occurrence  of  such  signs  have 


I 


Glanders.  153 

the  animal  tested  with  inallein  by  a  competent  veterinary  sur- 
geon. 

Public  Health  Administration. —  All  cases  ol  acute  glan- 
ders should  be  removed  at  once  to  hospital,  unless  their  homes 
are  such  as  admit  of  the  most  complete  isolation  with  good 
hygienic  surroundings.  C'lnonic  cases  niay  remain  at  home 
unless  their  houses  are  very  small  and  dirty,  in  which  case 
they  also  should  be  removed.  The  source  of  infection  must  be 
traced  and  all  horses  among  which  the  patient  was  working 
examined  and,  if  necessary,  tested  with  mallein  to  establish  a 
diagnosis  of  glanders  when  the  horse  is  the  subject  of  a  chronic 
or  latent  type  of  the  disease.  The  diseased  horse,  if  worth  the 
trouble,  may  be  treated  by  repeated  malleinisation ;  if  not,  it 
must  be  killed  and  the  carcass  destroyed.  The  stable  must 
be  cleaned,  washed  down  with  strong  formalin  solution,  and 
kept  under  supervision  by  the  veterinary  authority  for  some 
months. 


(    154   ) 


Chapter  XT. 

INFLUENZA. 

Synonyms. —  Epidemic     Influenza;     "the     Russian       In- 
fluenza." 
Ft.  :      La  Grippe. 
Ger.  :      Grippe. 

Definition. — An  acute  specific  fever,  characterised  by 
pyrexia,  pain  in  the  back  and  limbs,  headache,  and  disturb- 
ances of  the  gastro-intestinal  tract,  the  heart,  the  respiratory 
tract  and  brain,  due,  probably,  to  the  action  of  the  Bacillus 
Infiuenzce  discovered  by  Pfeiffer  in  1892, 

Incubation  Period. —  The  incubation  period  of  influenza 
is  very  short,  varying  from  one  to  three  days. 

Rash. — No  rash  has  been  observed  as  typical  of  the  disease. 

Clinical  Types. —  It  is  usual  to  describe  attacks  of  in- 
fluenza as  conforming  to  one  or  other  of  five  types,  the  simple 
febrile,  the  catarrhal,  the  hroncliitic,  the  gastro-intestinal  and 
the  cerebral,  but  it  is  unusual,  save  in  the  last,  to  have  in- 
fluenza occurring  without  some  degree  of  catarrh  in  the  res- 
piratory passages — the  classification  is  made  only  to  indicate 
what  the  outstanding  features  are  in  certain  groups  of  cases. 
The  siTnple  febrile  type,  has  generally  a  sudden  and  severe 
onset.  Without  a  moment's  warning  the  patient  may  be 
seized,  while  at  work  or  while  walking  in  the  street,  with  a 
severe  rigor,  accompanied  by  a  feeling  of  general  malaise  and 
great  enfeeblement,  so  that  he  can  hardly  drag  one  foot  after 
the  other.  Almost  immediately  he  may  suffer  from  nausea, 
vomiting,  giddiness  and  very  severe  headache  either  referred 
to  the  frontal  region  or  behind  the  eyeballs,  and  he  is  seized 


Influenza,  155 

with  acute  pain  in  the  back,  particularly  in  the  lumbar  region, 
and  aching  in  the  limbs,  referred  rather  to  the  muscles  and 
bones  than  to  the  joints.  He  is  conscious  of  a  dry  burning 
sensation  in  the  nose,  throat  and  eyes,  and  may  suft'er  from 
the  commencement  from  a  "  substernal  rawness."  The  tem- 
perature rises  at  once,  sometimes  as  high  as  105°  or  10G° 
F.,  and  a  temperature  of  104°  F.  is  very  commonly  observed. 

Pulse  and  respiration  are  greatly  increased  in  rate,  and 
the  patient  has  a  troublesome  frequent  cough  not  usually  ac- 
companied by  expectoration.  An  herpetic  eruption  frequently 
appears  about  the  lips,  and  blotchy  erythemata  have  been  oc- 
casionally observed  on  the  skin  of  the  trunk  and  limbs.  After 
some  three  days  of  pyrexia,  headache,  malaise,  prostration, 
anorexia,  pain  in  the  back  and  limbs,  and  dryness  in  throat, 
eyes  and  nose,  the  temperature  subsides  and  the  symptoms 
abate,  some  slight  coryza  and  faucial  secretion  appearing  as 
the  temperature  falls.  Convalescence  is  uncomfortable  and 
tedious,  and  it  may  be  many  months  before  a  patient  re- 
covers his  full  mental  and  physical  vigour,  although  his 
attack  has  been  of  the  simple  uncomplicated  febrile  type. 

In  the  catarrhal  type,  after  the  usual  symptoms  of  inva- 
sion, the  patient  is  seized  with  acute  catarrh  of  the  eyes  and 
nose,  lachrymation  may  be  extreme,  and  a  profuse  watery 
acrid  discharge  comes  from  the  nostrils.  The  nasal  discharge 
becomes  purulent,  and  the  conjunctivae  become  deeply  in- 
jected. The  fauces  and  tonsils  are  usually  acutely  inflamed, 
and  cough  is  troublesome,  and  may  be  attended  with  a  feeling 
of  "tearing"  behind  the  f'ternum  and  slight  mucous  expec- 
toration. Sleep  is  disturbed  on  account  of  the  obstruction  in 
the  nose.  Beyond  a  few  snoring  rhonchi  heard  in  the  upper 
part  of  the  chest,  no  physical  signs  are  apparent  on  examina- 
tion of  the  lungs.  The  catarrh  lasts  for  about  a  week  and 
then  clears  up,  sometimes  with  a  little  purulent  expectoration 
ejected  after  slight  coughing,  and  derived  presumably  from 
the  fauces  and  trachea. 

It  is  not  uncommon,  however,  for  such  catarrhal  cases  to 
assume  the  bronchitic  type,  where  the  inflammation  spreads 
from  the  fauces  and  trachea  to  the  bronchi  and  lungs,  and 
which  constitutes  one  of  the  most  dangerous  types  of  the  disease. 


166  Chapter  XI. 

Shortly  after  the  catarrhal  symptoms  appear  the  patient  is 
seized  with  a  sense  of  constriction  in  the  chest,  breathing  is 
rapid  and  difficult,  and  cough  is  almost  incessant  and  very 
distressing.  Expectoration  is  scanty  and  viscid,  sometimes 
purely  mucous,  sometimes  tinged  with  blood,  and  sometimes 
mixed  with  small  greenish  mucopurulent  masses,  but  always 
difficult  of  ejection.  Auscultation  of  the  chest  reveals  the 
presence  of  sibilant  rhonchi  and  a  few  sticky  rales.  In  a  cer- 
tain proportion  of  cases  the  temperature  subsides  in  about  a 
week.  Before  it  reaches  normal  the  expectoration  becomes 
mucopurulent  and  fairly  profuse  and  numerous  rhonchi 
with  mucous  and  sub-mucous  rales  are  audible  on 
auscultation  of  the  chest.  Even  after  the  temperature  has 
reached  normal,  the  cough,  expectoration  and  physical  signs 
remain  for  several  days  at  least  and  only  disappear  slowly  as 
convalescence  progresses.  In  other  cases,  however,  the  tem- 
perature remains  high  at  the  end  of  the  first  week,  and  the 
general  condition  of  the  patient  and  the  phj^sical  signs  make  it 
plain  that  the  catarrh  has  spread  to  the  bronchioles  and 
alveoli,  and  a  lobular  pneumonia  is  in  progress.  The  tem- 
perature may  be  very  high,  even  hyperpyretic,  the  patient 
tends  to  become  cyanosed  and  may  die,  with  gradually  in- 
creasing dyspnoea  and  slow  cardiac  failure.  In  some  epi- 
demics, shortly  after  the  occurrence  of  the  initial  catarrhal 
symptoms  a  lobar  pneumonia  develops  in  a  considerable  pro- 
portion of  cases,  which  slowly  involves  one  lung  and,  after 
the  lapse  of  a  week  or  ten  days,  at  a  time  when  crisis  might 
reasonably  be  expected  to  occur,  the  other  lung  may  become 
involved,  and  the  consolidation  spreads  in  it  as  in  the  lung  first 
attacked.  Such  cases  are  extremely  dangerous,  and  very 
often  fatal.  In  those  where  crisis  does  occur  the  patients 
tend  to  collapse  more  frequently  than  in  an  ordinary  lobar 
pneumonia,  and  if  they  rally  from  the  crisis  their  convales- 
cence is  difficult  and  protracted.  Delirium  is  very  common 
in  the  bronchitic  type,  especially  on  the  occurrence  of  pneu- 
monia, whether  lobar  or  lobular. 

The  gastro-intestinal  type  is  that  in  which  there  is  added 
to  the  symptoms  of  the  ordinary  febrile  type  the  symptoms  of 
an    acute    gastro-enteritis, — vomiting,     diarrhtiea    and    acute 


Influenza.  157 

abdominal  pain.  In  some  cases  the  ^astro-intestinal  symptoms 
are  very  urgent  and  the  patient  may  die  of  asthenia  or  col- 
lapse. 

Cases  are  occasionally  met  with  in  whicli  the  gastro- 
intestinal symptoms  are  the  first  which  present  themselves, 
and  in  these  the  diarrhoea  is  apt  to  he  very  profuse  and 
watery,  attacking  the  patient  with  great  suddenness,  and  fol- 
lowed by  profound  collapse,  almost  choleraic  in  its  intensity. 
Such  cases  very  frequently  prove  fatal. 

The  cerebral  or  nervous  type  is  not  common  in  Great 
Britain,  but  in  the  course  of  some  epidemics  has  been  met 
with  frequently  on  the  continent  of  Europe.  The  onset  of 
the  cerebral  symptoms  occurs  frequently  without  previous 
warning,  but  in  some  cases  it  is  preceded  by  a  few  days' 
malaise  with  aching  in  the  back  and  limbs  and  catarrh  of  the 
upper  rcvspiratory  passages.  The  patient  may  become  restless 
and  violently  delirious  and  may  suffer  from  acute  headache, 
and  stiffness  of  the  neck  and  of  the  muscles  of  the  jaw  may 
follow  later.  Tlie  delirium  lessens  in  a  few  days  and  the 
patient  may  die  comatose  or  slowly  recover.  In  other  cases 
severe  headache  or  pain  in  the  distribution  of  the  fifth  ner\e 
or  a  sudden  convulsion  may  be  the  first  indication  of  illness, 
and  these  may  be  quickly  followed  by  the  occurrence  of 
aphasia,  a  monoplegia,  or  hemiplegia,  and  stupor  or  coma 
may  supervene.  In  certain  cases  the  patient  may  suddenlv 
become  hemiplegic,  aphasic  and  comatose  without  having  been 
previously  ill,  as  in  a  case  of  sudden  cerebral  haemorrhage  or 
embolism.  It  is  a  striking  fact  that  in  the  cerebral  type  of 
influenza  there  may  be  practically  no  fever,  and  the  pulse 
rate  may  not  be  raised.  The  great  majority  of  attacks  of  the 
cerebral  type  prove  fatal  after  a  few  days'  illness,  but  occa- 
sionally recovery  takes  place. 

Afild  cases  of  influenza  are  very  frequently  met  with,  in 
fact  they  are  the  predominant  type  where  no  serious  epidemic 
is  raging.  As  a  rule  they  are  modifications  of  the  simple  feb- 
rile or  catarrhal  types,  and  have  an  insidious  onset  without 
rigor,  so  that  one  class  of  cases  may  present  the  characters  of 
an  ordinary  nasal  catarrh  with  perhaps  more  prostration 
during  convalescence  than  is  normal  to  a  common  cold,  while 


158  Chapter  XI. 

oiliers  suiter  from  headache,  pain  in  the  back  and  limbs, 
mental  depression  or  giddiness  with  little  or  no  fever.  Even 
in  such  modified  cases  convalescence  is  slow,  and  patients 
suffer  from  mental  depression,  loss  of  the  power  of  concentra- 
tion and  from  muscular  weakness  out  of  all  proportion  to  the 
severity  of  their  illness.  It  is  usual  to  describe  the  primarily 
bronchitic  as  the  most  dangerous  of  all  the  types  of  influenza, 
but  many  practitioners  will  agree  that  the  most  dan- 
gerous of  all  is  that  which  begins  as  a  mild  form  of  the  disease 
with  little  fever  and  few  symptoms  of  catan'h,  so  that  the 
patient  does  not  immediately  lie  up,  but  struggles  on  for  days 
until  he  falls  a  victim  to  one  or  other  of  the  graver  manifes- 
tations of  the  disease.  An  attack  of  influenza  with  an  acute 
and  severe  onset  protects  by  its  very  severity,  and  even  if  it 
develops  as  the  bronchitic  type  of  the  disease,  the  patient, 
having  been  under  observation  from  the  onset,  is  more  likely 
to  survive  a  severe  bronchitis  or  a  pneumonia  than  one  who 
has  been  weakened  by  over-exertion  and  exposure  while  suf- 
fering from  a  mild  type  of  the  disease  with  insidious  onset, 
before  the  development  of  pulmonary  trouble. 

Diagnosis. — A  typical  attack  of  the  simple  febrile  or  the 
catarrhal  type  is  usually  easy  of  diagnosis,  the  only  disease 
likely  to  be  confused  with  a  simple  febrile  attack  being  acute 
rheumatism,  and  there  the  definite  location  of  pain  in  the 
joints  and  the  less  sudden  onset  will  help  to  make  the  dis- 
tinction plain.  In  the  pulmonary  type,  if  there  is  much  con- 
solidation of  lung,  the  clinical  differentiation  of  an  influenzal 
from  an  ordinary  acute  pneumonia  is  very  difficult,  and,  in 
those  cases  where  the  influenzal  pneumonia  is  frankly  lobar, 
impossible,  without  bacteriological  examination  Similarly, 
accurate  diagnosis  in  the  mild  catarrhal  types  is  also  impos- 
sible without  the  recovery  of  the  bacillus.  In  the  cerebral 
type,  lumbar  puncture  should  be  performed  when  the  symp- 
toms simulate  those  of  a  meningitis,  to  exclude  the  possibility 
of  the  case  being  one  of  epidemic  cerebro-spinal  or  tuber- 
culous meningitis. 

Certain  cases  of  influenza  are  mild  and  prolonged,  with  a 
tendency  to  relapse,  and  the  use  of  Widal's  test  will  help  to 
differentiate   such   cases   from   enteric  fever,   and   the  use   of 


Influenza.  159 

Calmette's  ophthalmic  reaction  or  of  Von  Pirquet's  cutaneous 
reaction  will  help  to  exclude  certain  forms  of  tuberculosis 
which  they  may  closely  resemble.  It  is  generally  supposed 
that  the  bacillus  influenzoe  of  Pfeiffer  is  the  causal  agent  in 
epidemic  influenza,  and  this  organism  may  be  recovered  from 
the  upper  air-passages  and  the  sputum.  The  bacillus  is  small 
and  slender,  with  a  tendency  to  stain  at  the  poles  and  not  at 
the  centre.  Gram-negative  and  growing  only  on  media  which 
contain  haemoglobin.  It  is  very  rarely  found  in  the  blood- 
stream, and  does  not  give  rise  to  true  purulent  meningitis. 
Cohen  has  described  in  the  Anmales  de  V  Institut  Pasteur 
(1909,  xxiii,  273),  a  bacillus  which  he  recovered  from 
the  blood  stream  and  from  the  subarachnoid  space  in 
certain  cases  of  purulent  meningitis,  and  which  resembles  the 
B.  influenzae  of  Pfeiffer  both  morphologically  and  in  cultural 
characteristics,  but  has  a  different  pathogenicity  towards 
animals.  This  organism  may  bear  the  same  relation  to  the  B. 
influenzae  as  does  the  B.  paratyphosus  to  the  B.  typhosus. 

AVithout  the  recovery  of  the  B.  influenzae  it  may  be  quite 
impossible  to  differentiate  a  mild  catarrhal  type  of  the  disease 
from  the  infectious  coryza  due  to  the  micrococcus  catarrhalis, 
in  which  a  certain  amount  of  shivering  and  pain  in  the  limbs 
is  very  frequently  met  with. 

Complications.  —  Cardiac  degeneration  with  dilatation  and 
failure  are  two  of  the  most  serious  complications  of  influenza, 
and  while  they  occur  more  frequently  in  cases  of  a  severe 
bronchitic  or  pneumonic  type  they  do  occur  in  cases  where 
the  other  symptoms  have  been  deceptively  mild.  The  symp- 
toms are  breathlessness,  even  on  slight  exertion,  a  rapid  and 
irregular  pulse,  and  some  degree  of  cyanosis.  The  heart  may 
be  markedly  enlarged  to  either  side  on  percussion,  and 
systolic  murmurs  may  be  audible  at  both  the  mitral  and  tri- 
cuspid areas.  The  symptoms  of  dilatation  and  failure  of  the 
heart  not  infrequently  follow  some  exertion  on  the  part  of  the 
patient  or  after  he  has  been  permitted  to  sit  up  or  walk  too 
soon.  Death  may  occur  with  great  suddenness,  while  in  some 
cases  the  symptoms  may  persist  for  many  weeks  or  even 
months  before  death  supervenes,  and  in  others  a  slow  and 
tedious  recovery  is  made.       Pericarditis  and  endocarditis  are 


160  Chapter  XL 

occasionally  met  with,  and  a  few  cases  of  acute  infective 
endocarditis  as  part  of  an  influenzal  septicaemia  have  been 
recorded. 

Various  swpinirative  affections  are  met  with  as  compli- 
cations in  influenza,  the  more  common  of  which  are  acute 
purulent  otitis  media,  abscess  in  the  antrum  of  Highmore  and 
empyema  of  the  frontal  sinuses.  From  these  conditions,  as 
from  the  acute  suppurative  "parotitis  which  occasionally  occurs, 
the  B.  influenzae  has  been  recovered.  Pleurisy,  both  dry  and 
with  effusion,  and  eTnpyeina  are  occasionally  met  with,  and 
laryngitis,  both  acute  and  subacute,  sometimes  occurs.  In  rare 
instances  haeanorrhages  occur  from  the  nose,  lungs  or  intestine, 
and  an  optic  neuritis  which  does  not  usually  proceed  to 
atrophy  has  been  described  as  an  unusual  complication. 

Sequelae. — During  convalescence  the  patient  is  pecu- 
liarly susceptible  to  chill,  and  bronchitis  and  pneumo7iia  of  a 
very  dangerous  kind  may  follow  on  any  undue  exposure 
during  convalescence.  It  is  said  that  phthisis  is  apt  to  follow 
■on  an  attack  of  influenza,  and  also  that  an  attack  of  influenza 
wall  cause  an  exacerbation  of  his  disease  in  a  phthisical 
patient,  but  it  would  be  well  if  these  statements  were  founded 
■on  careful  bacteriological  examination,  as  it  is  a  matter  of 
common  observation  that  the  onset  of  phthisis  pulmonalis  may 
in  certain  cases  very  closely  resemble  the  onset  of  influenza, 
and  curious  attacks  of  fever  with  prostration  are  met  with  in 
the  course  of  phthisis,  although  in  neither  class  of  case  has 
the  B.  influenzae  been  isolated  from  the  sputum  or  nasal 
secretion. 

The  most  troublesome  and  constant  sequelae  are  those 
affecting  the  Tnuscular  and  nervous  systems,  where  lassitude, 
muscular  weakness,  a  rapid  pulse,  mental  depression  and  loss 
of  the  power  of  concentration  may  persist  for  many  months 
after  the  attack  has  passed  off.  A  tendency  to  vertigo  may 
also  persist  for  a  long  time.  Peripheral  neuritis  has  been  ob- 
served, but  rarely.  It  is  no  uncommon  thing  for  a  man  whose 
work  is  mental  and  taxing  to  find  that  he  is  unable  to  study 
for  many  months  after  his  attack  of  influenza,  and  he  is  con- 
scious during  that  time  that  his  "head  is  easily  tired"  and  that 
he  is  incapable  of  prolonged  concentration,  while  his  memory. 


Influenza.  161 

although  previously  good,  has  become  very  treacherous. 
This  loss  of  mental  power  tends  to  increase  the  depression 
which  is  so  usual  during  convalescence,  and  a  true  melancholia 
may  supervene,  in  the  course  of  which  a  suicidal  tendency 
may  develop.  In  an  epidemic  of  influenza  in  Scotland 
in  1890,  an  athletic  highly  educated  young  man  who  was 
one  of  the  school  inspectors  appointed  under  the  Scottish 
Education  Department  contracted  tlie  disease,  and,  altliough, 
his  attack  was  only  a  moderately  severe  one  of  the  simple 
febrile  type,  his  mental  depression  was  such  that  during  con- 
valescence he  went  to  the  railway  and  laid  his  head  down 
before  an  advancing  express  train.  The  form  of  mental  de- 
rangement which  follows  influenza  is  usually  melancholia,  but 
various  forms  of  mania  have  also  been  described.  All  kinds  of 
neurasthenic  and  psychasthenic  manifestations  are  apt  to 
occur.  The  sense  of  taste  and  smell  may  be  impaired  for 
long  after  convalescence  is  established. 

Treatment. — An  essential  in  the  treatment  of  influenza  is 
that  the  patient  should  be  kept  in  bed  from  the  beginning  of 
his  attack  until  the  evening  temperature  has  been  normal  for 
at  least  three  days,  and  until  all  catarrhal  symptoms  have  dis- 
appeared. Thereafter  he  should  remain  indoors  for  some  days, 
and  should,  if  possible,  take  a  holiday  of  some  weeks'  dura- 
tion before  resuming  w^ork,  more  especially  if  his  work  in- 
volves worry  or  mental  strain.  In  this  way  many  fatalities, 
and  much  of  the  distress  caused  by  prolonged  physical  and 
mental  weakness  during  convalescence  would  be  avoided. 

During  the  acute  stage  headache  and  fever  may  be  re- 
lieved by  sponging  with  cold  or  tepid  water  or  by  the  appli- 
cation of  cold  compresses,  as  in  enteric  fever.  A  mustard 
plaster  very  often  relieves  the  pain  in  the  back.  A  combina- 
tion of  sodium  salicylate  (grs,  iii),  and  the  Liquor  of  the 
Acetate  of  Ammonia  (Tl|^xx)  repeated  every  two  hours  is 
efficacious  in  promoting  a  reasonable  moisture  of  the  skin, 
and  in  relieving  pain  in  the  limbs;  it  tends,  moreover,  to 
lessen  the  intense  feeling  of  congestion  in  the  nose  and  frontal 
sinuses,  which  is  often  so  distressing.  Quinine  in  the  form  of 
the  ammoniated  tincture  is  also  of  service  in  cases  where  there 
is  much  fever,  and  should  be  given  in   doses  of  3i  repeated 


M 


162  Chapter  XI. 

every  three  or  four  liours.  When  there  is  any  bronchitis  or 
laryngeal  inflammation,  Ammonium  carbonate  (grs.  iii.)  may 
be  given  in  combination  with  spirit  of  Chloroform  (TI^  sv.), 
and  Camphor  water  (^i),  the  mixture  to  be  repeated  every 
two  hours,  and  hot  inhalations  containing  oil  of  Eucalyptus  or 
Thymol  will  often  relieve.  I  have  found  that  a  dry  inhala- 
tion composed  of  Tr.  lodi  Aetherialis,  01.  Creosoti,  01. 
Eucalypti,  et  Spt.  Chloroformi,  in  equal  parts,  is  very  ser- 
vicable  when  there  is  any  bronchial,  tracheal,  or  laryngeal 
catarrh,  giving  ten  drops  on  the  sponge  of  a  Squire's  oro-nasal 
inhaler  to  be  used  for  fifteen  minutes  frequently  during  the 
twenty-four  hours.  The  application  of  heat  to  the  front  of  the 
chest  will  often  relieve  the  painful  feeling  of  constriction  even 
in  adults.  In  bronchitic  and  pneumonic  cases  the  state  of  the 
pulse  and  restlessness  of  the  patient  may  demand  the  use  of 
whisky  or  brandy,  and  this  is  best  given  in  two  or  three  doses 
in  the  twenty- four  hours  of  §i  each  rather  than  distributing 
the  same  amount  over  the  day  in  small  doses  every  three  or 
four  hours.  When  there  is  much  restlessness  and  delirium ^ 
without  any  pulmonary  or  bronchial  catarrh,  the  hypodermic 
injection  of  ^th  gr.  of  morphine  may  be  used  with  advantage, 
and  repeated  every  three  hours  until  quiet  is  produced. 

In  cases  where  coma  had  supervened.  Sir  William  Broad- 
bent  recommended  intramuscular  injection  of  several  grains  of 
the  hydrobromate  of  quinine,  repeated  if  necessary  three  or 
four  times  in  the  day. 

In  cases  which  have  shown  acute  cardiac  failure  it  is  best 
to  use  the  hypodermic  injection  of  strychnine,  gr.^Vj  with 
some  twenty  minims  of  ether,  and  to  push  digitalis  after  the 
patient  has  once  rallied.  In  all  cases  where  the  pulse  con- 
tinues to  be  rapid,  say  over  110  for  several  days,  digitalis 
should  be  used  freely,  combined,  when  there  is  much  general 
irritability,  with  Ammonium  bromide  in  doses  of  10-20 
grains. 

Suppurative  complications  must  be  dealt  with  surgically 
as  they  arise. 

The  muscular  and  mental  weakness  which  is  so  trouble- 
some during  convalescence  should  be  treated  by  rest,  change 
of  scene  and  cheerful  surroundings,  while  the  bi-hydrochloride 


Influenza.  lO'j 

of  Quinine  in  doses  of  half  a  grain,  with  5  minima  of  dilute 
nitro-hydrochloric  acid,  3-5  minims  of  the  Liquor  of  Stry- 
chnine and  some  Compound  Infusion  of  Gentian  may  be  given 
with  advantage  thrice  daily  before  food.  It  is  of  the  utmost 
importance  that  any  patient  who  shows  the  slightest  tendency 
to  melancholia  should  be  very  carefully  watched  on  account  of 
the  liability  which  such  people  show  to  develop  suicidal 
tendencies. 

Diet. — The  diet  during  the  acute  stage  of  influenza 
should  be  bland  and  fluid,  iced  if  the  patient  so  desires  it, 
and  should  consist  rather  of  very  thin  gruels,  milk  diluted  with 
soda-water  or  barley-water,  and  barley-water  itself  rather  than 
soup,  to  which  many  patients  profess  a  strong  objection. 

As  convalescence  is  established,  a  generous  diet  should  be 
given  as  soon  as  the  patient's  appetite  permits,  and  the 
greatest  care  should  be  taken  that  its  nutritive  value  is  high. 
To  those  who  are  accustomed  to  the  use  of  alcohol  in  health 
it  should  be  given  during  convalescence,  as  the  sense  of  well- 
being  which  it  induces  is  of  value,  but  it  should  not  be  urged 
on  those  who  are  not  accustomed  to  take  it,  as  the  very  sense 
of  well-being  which  it  produces  may  cause  the  establishment 
of  a  habit  of  alcoholism  in  those  who  were  previous!^' 
abstainers. 

Epidemiology. — Influenza  swept  across  Europe  from  Russia 
in  1889,  and  since  1890  Great  Britain  has  been  liable 
each  winter  to  epidemics  of  greatly  varying  severity.  In  some 
years  the  disease  has  shown  itself  mainly  as  an  unusually 
severe  kind  of  nasopharyngeal  catarrh  which  has  tended  in 
certain  cases  to  spread  to  the  bronchi,  and  after  which  con- 
valescence was  tedious,  while  in  others  the  grave  types  have 
predominated,  and  patients  have  died  in  considerable  numbers 
from  influenza  of  the  pulmonary  and  intestinal  types.  One 
attack  confers  little  or  no  immunity.  It  is  a  common  thing  to 
find  that  patients  have  had  two  attacks  of  moderately  severe 
influenza  in  the  same  winter,  but  many  who  seem  to  fall  a 
victim  to  the  disease  almost  every  year  say  that  the  first  at- 
tack they  had  was  severe  and  typical,  while  the  subsequent  two 
or  three  attacks  have  been  atypical  and  mild,  but  that  after  a 
few  mild  attacks,  they  have  again  suffered  from  a  severe  and 

M      2 


164  Cluipter  XL 

typical  iuHiienza  which  is  again  followed  by  two  or  three  mild 
attacks,  and  so  the  rotation  goes  on.  It  is,  however,  difficult 
to  be  certain  about  the  accuracy  of  their  statements,  as  any 
infectious  coryza  associated  with  aching  in  the  limbs  and  back 
is  too  readily  diagnosed  as  influenza  at  the  present  day. 

Method  of  Infection. —  Influenza  can  be  spread  by  direct 
contact  with  infected  persons,  and  also  by  means  of  various 
fomites,  such  as  clothing,  furniture,  letters,  parcels,  &c.  Most 
severe  epidemics  are  preceded  by  the  occurrence  of  a  few 
sporadic  cases,  which  presumably  spread  the  disease  among 
those  with  whom  they  come  in  contact.  The  tendency  for  in- 
fluenza to  spread  through  institutions  and  households  is  in 
itself  proof  of  its  great  infectivity. 

Period  of  Infectivity. — Wliile  it  is  true  that  the  disease 
is  most  infectious  in  its  early  stages,  patients  are  capable  of 
conveying  the  infection  to  others  directly  for  at  least  some 
days  after  the  acute  symptoms  have  subsided,  and  it  is  prob- 
able that  infected  fabrics  are  capable  of  retaining  the  infec- 
tion for  a  long  time  after  they  have  been  in  contact  with  a 
patient  suffering  from  influenza.  It  seems  likely,  judging  from 
the  frequent  small  outbreaks  of  the  disease  in  country  dis- 
tricts which  occur  shortly  after  the  arrival  of  supposed  con- 
valescents on  holiday,  that  we  are  too  careless  in  our  isolation 
of  cases  of  influenza  and  in  the  disinfection  of  clothing  and 
other  articles  which  have  been  exposed  to  the  infection. 

Death-Rate. — The  percentage  mortality  among  cases  at- 
tacked is  small,  but  in  any  widespread  epidemic  so  many  of 
the  community  are  attacked  by  the  disease  that  the  fatal  cases 
cause  a  marked  increase  in  the  local  death-rate  during  the 
period  of  the  epidemic.  Influenza  is  much  more  fatal  in 
elderly  people  than  among  young  adults,  while  children 
usually  exhibit  a  mild  type  of  the  disease.  Pre-existing  car- 
diac disease,  a  tendency  to  bronchitis,  any  organic  disease  of 
the  kidneys  or  liver,  or  a  bad  history  with  regard  to  alcoholic 
excess  are  all  factors  which  militate  against  the  recovery  of  a 
patient.  The  mortality  is  high  among  those  who  show  severe 
cerebral  or  gastro-intestinal  symptoms,  who  have  much  bron- 
chial catarrh,  who  develop  pneumonia,  either  lobar  or  lobular, 
or  show  any  marked  tendency  to  cardiac  failure. 


Influenza.  165 

Home  Prophylaxis. — A  patient  suffering  fjoiu  influenza 
ought  to  be  isolated  as  fax  as  possible  from  the  other  members 
of  the  household;  his  room  should  be  vacated  at  the  end  of 
the  attack  and  its  contents  disinfected  before  it  is  re-occupied. 
All  bed  clothes  and  washable  materials  in  the  room  should  be 
steeped  in  a  1-20  solution  of  carbolic  acid  and  afterwards 
washed.  The  carpets,  hangings,  furniture,  and  outer  clothing 
ought  to  be  sprayed  with  formalin  solution  and  thoroughly 
aired  before  being  used  again,  while  the  walls  should  be  ex- 
posed for  twenty-four  hours  to  the  vapour  of  formalin,  and 
the  room  freely  ventilated  for  at  least  a  day.  It  would  seem 
probable  that  the  organism  of  influenza  is  capable  of  living 
for  long  periods  in  furniture,  in  the  corners  of  rooms,  and  in 
clothing  which  has  been  exposed  to  infection.  I  know  of  one 
family,  the  members  of  which  were  for  years  the  victims  of 
attacks  of  influenza  of  a  very  typical  kind  occurring  in  early 
winter  or  spring  until  they  thoroughly  disinfected  their  house 
and  furniture,  besides  the  usual  repapering  and  painting  of 
the  rooms,  during  one  summer  when  they  were  on  holiday.  In 
the  past  two  years  no  member  of  that  household  has  suffered 
from  influenza. 

Public  Health  Administration, — Although  influenza  is  not 
a  notifiable  disease,  it  is  well  that  the  local  authority 
should  afford  facilities  for  the  disinfection  of  houses  and 
clothing  to  those  who  may  desire  it,  and  who  are  unfavourably 
situated  for  the  carrying  out  of  efficient  disinfection  for  them- 
selves. 


( i^« ) 


Chapter    XII. 


PULMONAEY   TUBEECULOSIS. 

Synonyms  : — Consumption;  Phthisis  Pulmonalis. 
French  :      La  Phthisie. 
German :      Schwindsucht. 

Definition. — An  inflammatory  process  in  the  lungs  charac- 
terised by  catarrh,  consolidation,  caseation  and  fibroid  changes, 
caused  by  the  B.  tuberculosis,  discovered  hj  Koch  in  1882. 

Incubation  Period. — The  incubation  period  of  phthisis 
pulmonalis  is  quite  indefinite.  The  only  case  which  I  have 
known  in  which  it  seemed  likely  that  the  time  of  infection 
could  be  fixed  with  any  accuracy  was  where  a  young  woman 
was  undergoing  a  course  of  *'  Weir-Mitchell  "  treatment  in  a 
nursing  home.  She  was  in  the  home  for  some  eight 
weeks,  and  three  months  after  she  left,  she  developed  symp- 
toms which  made  her  physician  suspect  the  existence  of 
phthisis  pulmonalis,  and  the  sputum  was  found  to  contain 
large  numbers  of  the  B.  tuberculosis.  Enquiry  was  made  at 
the  nursing  home  with  a  view  of  discovering  a  possible  source 
of  infection,  and  it  was  found  that  the  patient  who  had  been 
the  last  occupant  of  the  room  in  which  the  young  woman 
received  her  "  Weir-Mitchell ''  treatment,  had  died  of  an 
advanced  tuberculosis  of  the  lungs,  and  the  room  had  not  been 
disinfected  before  the  admission  of  another  patient. 

It  is  probable  that  the  incubation  period  may  be  anything 
between  a  week  or  two  and  some  years,  during  which  the 
bacillus  lies  latent  and  produces  no  apparent  disturbance  of 
the  patient's  health.  But  anything  like  accurate  determina- 
tion is  usually  impossible,  as  it  is  only  after  repeated  exposure 


Pulmonary  Tiiherculons.  167 

to  infection,  and  even  then  most  commonly  as  tlie  result  of  an 
hereditary  predisposition  or  a  loss  of  resistance  on  the  part  of 
the  patient  due  to  tlie  influence  of  some  other  disease,  that 
pulmonary  tuberculosis  is  acquired. 

Rash.  —No  rash  has  been  observed  as  typical  of  the  disease, 
but,  as  in  all  the  acute  infectious  fevers,  erythemata  and 
morbilliform  rashes  have  been  observed  as  unusual  occurrences 
in  its  course. 

Clinical  Types. — In  discussing  the  clinical  types  of  pul- 
monary tuberculosis  I  do  not  propose  to  describe  at  any  length 
the  physical  signs  to  be  met  with  in  the  lungs,  as  they  fall 
more  naturally  to  be  described  in  a  treatise  on  general  medi- 
cine, and  I  shall  merely  indicate  briefly  the  signs  met  with 
in  the  several  types  v/hich  are  necessary  for  the  diagnosis 
of  the  disease  and  its  complications. 

The  clinical  types  usually  described  are  miliary  tubercle  of 
the  lung,  yneuTnonic  'phthisis,  chronic  phthisis  with  softening, 
and  fibroid  phthisis. 

Miliary  tubercle  of  the  lung  is  commonly  a  part  of  a 
general  infection  b}^  the  B.  tuberculosis  of  the  whole  body  and 
the  lungs  are  affected  along  with  the  other  viscera.  Its  onset, 
unless  ushered  in  by  the  occurrence  of  meningeal  symptoms, 
resembles  that  of  enteric  fever.  Physical  signs  in  the  lungs 
are  frequently  absent,  and  if  present  they  resemble  those  of  an 
acute  catarrhal  affection  involving  the  smaller  bronchi — diffuse 
sibilant  rhonchi,  mucous,  submucous  and  subcrepitant  rales. 
When  the  pleura  are  involved  some  fine  crepitus  will  be 
aiidible. 

As  a  rule  there  is  a  widespread  diminution  in  the  volume 
of  the  respiratory  murmur,  and  small  areas  of  dull  percussion 
may  be  detected,  while  it  is  not  at  all  uncommon,  especially 
in  children,  to  find  that  the  front  of  the  chest  yields  a  hyper- 
resonant  note  on  percussion,  due  possibly  to  an  acute  emphy- 
sema. The  temperature  is  raised,  and  may  be  high,  102°  and 
103°  F.  being  quite  usual  readings.  The  fever  is  usually 
of  the  continued  type.  The  pulse  is  rapid  and  soft.  Breathing 
is  difficult  and  rapid,  and  there  is  in  the  great  majority  of 
cases  very  marked  cyanosis  of  the  lips,  face  and  extremities. 


168  Chapter  XII. 

even  of  the  skin  generally.  Witli  this  type  of  pulmonary 
tuberculosis  the  spleen  and  liver  may  be  enlarged,  meningitis 
may  develop,  and  tubercles  may  be  visible  in  the  choroid. 
There  may  be  acute  diarrhoea  or  constipation  with  considerable 
swelling  of  the  abdomen.  It  may  be  said  definitely  that  this 
form  of  the  disease  is  always  fatal,  and  may  run  its  course  in 
a  week  or  two.  Sometimes,  however,  it  may  be  protracted 
for  several  weeks,  or  even  months. 

Pneumonic  phthisis  :  In  this  type  of  the  disease  the  lesion 
may  have  the  character  of  a  lobar  'pneuTnonia  or  of  a  hroncho- 
■pneumonia.  The  onset  is  usually  sudden  and  severe,  often 
with  rigor,  and  the  patient  suffers  much  with  cough  and 
pulmonaiy  distress.  The  physical  signs  may  be  those  of  lobar 
pneumonia,  and  nothing  save  the  examination  of  the  ispit  may 
give  any  indication  of  the  infecting  organism.  In  certain 
lobar  cases  the  disease  may  be  fatal  within  the  first  fortnight^ 
but  as  a  rule,  its  course  is  more  prolonged  than  an  ordinary 
acute  lobar  pneumonia,  and  death  does  not  commonly  occur 
until  the  patient  has  been  ill  for  a  couple  of  months.  The 
temperature  at  the  first  behaves  just  like  that  of  an  acute  lobar 
pneumonia,  and  physical  examination  shows  that  one  lobe 
or  more  of  a  lung  is  in  a  stage  of  consolidation.  Instead,  how- 
ever, of  having  a  crisis  about  the  seventh  or  eleventh  day,  as  in 
an  ordinary  acute  lobar  pneumonia,  the  condition  tends  to  be 
aggravated,  the  temperature  becomes  markedly  remittent  and 
the  pulse  rate  increases,  the  sputum  becomes  muco-purulent 
and  often  has  a  greenish  colour.  Signs  of  softening  are  to 
be  made  out  in  the  lung  and  the  examination  of  the  sputum 
will  reveal  the  presence  of  tubercle  bacilli  and  elastic  tissue. 
In  the  majority  of  cases  death  occurs  at  anything  between  the 
third  week  and  the  third  or  fourth  month,  but  in  some  cases 
the  acute  symptoms  pass  off  and  the  disease  assumes  a 
chronic  type. 

In  those  cases  where  the  lesion  is  hroncho-pnewtnonic ,  the 
onset  is  also  sudden  and  acute,  resembling  closely  the  onset  of 
an  ordinary  broncho-pneumonia.  At  the  end  of  a  week  or  two, 
however,  the  symptoms  show  no  abatement,  the  temperature 
takes  on  a  markedly  remittent  character,  and  the  patient  may 
die  after  an  illness  of  a  few  months,  or  the  disease  may  drift 


Pulmonary  Tuberculosis.  1(50 

into  the  chronic  form.  There  is  nothing  in  the  character  of 
the  physical  signs  to  indicate  that  the  broncho-pneumonia  ia 
tuberculous,  as  they  differ  in  no  way  from  those  of  a  broncho- 
pneumonia of  an  ordinary  type. 

In  both  kinds  of  pneumonic  phthisis  the  patient  is  cojn- 
monly  flushed  at  the  onset,  but  becomes  more  or  less  cyanosed 
as  the  disease  progresses.  The  lesions  in  the  lung  tend  to  be 
more  frequently  apical  than  in  non-tuberculous  pneumonia 
and  broncho-pneumonia. 

Clironic  "phthisis  with  softening.  —  This  type  may  be 
chronic  from  the  commencement  of  the  disease,  or  may  result 
from  one  or  other  of  the  pneumonic  types.  Where  the  onset 
has  been  acute  and  severe  the  chronic  type  develops  from  the 
pneumonic  by  a  gradual  modification  of  the  symptoms.  Fever 
becomes  less  marked,  cough  and  wasting  are  not  so  urgent,  the 
patient  loses  the  flushed  febrile  look  and  begins  to  feel 
stronger  and  have  more  appetite.  The  physical  signs  in  the 
chest  tend  to  limit  themselves  to  one  or  other  upper  lobe, 
collateral  catarrh  disappears,  and  the  definite  lesion  com- 
pounded of  catarrh,  consolidation  and  softening  becomes 
gradually  more  and  more  apparent.  Excavation  may  proceed 
and  a  cavity  form,  or  the  disease  may  spread  to  other  parts  of 
the  lung  and  the  phenomena  of  moist  crepitations,  bronchial 
breathing  or  signs  of  cavity  may  be  discovered  in  the  lower 
parts  of  the  lung,  whereas  the  primary  lesion  was  situated  in 
the  upper.  Pleurisy  may  develop,  with  or  without  effusion. 
As  the  softening  proceeds  the  sputum  becomes  muco-purulent 
and  even  frankly  purulent,  while  as  a  cavity  forms  the 
typical  ''nummular"  expectoration  may  be  met  with.  The 
temperature  is,  as  a  rule,  markedly  remittent,  with  a  morning 
fall  and  an  evening  exacerbation.  The  daily  variation  may 
be  large,  and  it  is  not  uncommon  during  the  course  of  one  of 
the  more  rapidly  advancing  cases  of  the  chronic  type  to  have 
frequent  febrile  movements  of  considerable  severity.  In  a 
certain  proportion  of  cases  the  disease  goes  on  to  spontaneous 
cure,  even  after  treatment  of  the  most  inadequate  description. 
The  moist  sounds  in  the  lung  disappear,  constitutional  symp- 
toms abate,  and  cavities,  even  of  considerable  size,  dry  up  and 
shrink,  causing  little  embarrassment.    In  other  cases,  however. 


170  Chapter  XII. 

the  disease  does  not  tend  to  cure,  but  steadily  advances  with 
variable  rapidity.  Febrile  exacerbations  are  common,  and  the 
patient  suffers  from  a  profound  toxaemia  begotten  both  of  the 
B.  tuberculosis  and  the  pyogenic  infections  which  are  so  com- 
mon in  the  softening  lung.  An  acute  pneumonia  or  broncho- 
pneumonia may  be  superadded  to  the  tuberculous  condition, 
and  even  after  years  of  chronicity  the  patient  may  die  of  an 
acute  form  of  phthisis  following,  apparently,  on  the  occur- 
rence of  some  acute  infection  other  than  tubercle.  Death  may 
ensue  from  asthenia  or  one  of  the  numerous  complications 
which  may  occur. 

The  great  majority  of  cases  of  phthisis  are,  however, 
chronic  from  the  beginning.  Their  onset  is  insidious  and 
slow,  and  it  may  be  long  before  a  patient  feels  ill  enough  to 
consult  a  physician  and  further  delay  may  result  from  diffi- 
culties in  early  diagnosis.  A  slight  "cold"  which  does  not 
get  well  properly  and  which  is  accompanied  with  cough,  an 
unexplained  ansemia,  dyspepsia,  loss  of  weight,  and  an  in- 
creasing sense  of  lassitude  and  "unfitness,"  may  be  the  first 
indications  that  anything  is  wrong,  and  even  when  the  patient 
comes  under  observation  it  may  be  long  before  any  physical 
signs  are  discovered  in  the  chest.  Soon,  however,  a  little 
dullness  at  one  or  other  apex  or  over  the  apex  of  the  lower 
lobe  of  a  lung  becomes  apparent,  and  auscultation  reveals  a 
degree  of  bronchial  breathing  which  varies  with  the  situation 
of  the  lesion,  being  sometimes  loud  and  marked  and  sometimes 
distant  and  difficult  of  detection.  At  the  same  time  it  is 
usual  to  be  able  to  detect  at  least  a  few  rales  with  inspiration, 
although  these  may  be  masked  by  the  development  of  a  bron- 
chitis which  is  confined  to  the  apical  region  of  one  or  other 
lung.  In  some  cases  a  fairly  widespread  bronchial  catarrh 
may  be  the  first  lesion  detected  in  the  chest,  and  may  give 
rise  to  no  suspicion  until  it  is  found  that,  while  it  clears  up 
in  other  parts  of  the  lungs,  it  lingers  at  an  apex.  Sometimes 
the  occurrence  of  hfemoptysis  is  the  first  sign  of  illness,  and 
after  this  occurrence  the  signs  of  a  lesion  at  one  apex  usually 
develop  fairly  quickly.  The  progress  of  a  case  after  an  early 
apical  lesion  is  detected  varies  much  in  individuals  according 
to    their    natural    resistance    and    their    social    and    climatic 


Puhnonary  Tuhermdons.  171 

enviroument.  In  cases  where  tlie  patient  lias  command  of 
money  or  influence  or  lias  no  people  directly  dependent  on 
him,  he  may  be  placed  under  circumstances  which  will  lead 
at  least  to  an  arrest  of  the  tuberculous  process,  and  be  able  to 
afford  himself  the  leisure  and  the  freedom  from  money-earn- 
ing which  is  a  necessary  part  of  the  treatment.  In  a  certain 
number  of  cases  a  naturally  great  resistance  will  enable  him  to 
keep  the  disease  in  check  even  under  unfavourable  circum- 
stances, but  in  the  great  majority  of  patients  who  are  the 
subject  of  phthisis,  unless  able  to  undergo  treatment  under 
very  favourable  climatic  and  hygienic  conditions,  the  disease 
develops  and  spreads  until  death  follows  on  years  of  useless- 
ness  and  invalidism  during  which  the  patient  has  the  misery 
of  seeing  his  occupation  slip  from  him  and  his  immediate 
dependents  living  either  on  the  resources  of  the  parish  or  the 
goodwill  of  friends.  Catarrh,  consolidation,  softening  and 
excavation  extend,  and  the  patient  dies  from  asthenia  or  from 
some  complication  as  already  described.  The  refractoriness  of 
certain  cases  which  show  few  and  insignijficant  physical  signs 
in  the  chest  leads  one  to  suspect  that  a  widespread  but  deeply- 
seated  lesion  may  express  itself  most  inadequately  by  appre- 
ciable physical  signs.  In  estimating  the  severity  and  progress 
of  a  case  of  chronic  phthisis  the  general  condition  of  a  patient 
is  of  far  greater  value  than  the  physical  signs  in  the  chest;  it 
is  not  the  local  but  the  constitutional  effects  of  the  toxins 
which  are  to  be  dreaded.  Everybody  is  familiar  with  the 
man  who  lives  on  with  half  his  lung  tissue  gone,  and  also 
with  the  unfortunate  who  dies  with  a  local  lesion  curiously 
disproportionate  to  the  severity  of  his  general  symptoms.  The 
consideration  of  these  natural  variations  of  the  disease  are  of 
the  utmost  importance  when  the  question  of  treatment  comes 
to  be  considered. 

Fibroid  phthisis. — In  this  type  of  the  disease  the  main 
lesion  is  a  fibrosis  of  the  lung  which  may  follow  on  a  tuber- 
culous pleurisy  with  thickening  of  the  pleura,  or  on  a  chronic 
tuberculous  broncho-pneumonia.  In  many  cases  it  follows  on 
the  arrest  and  limitation  of  a  chronic  tuberculosis  of  the  lung 
where  a  cavity  has  formed  which  becomes  surrounded  with  a 
dense  layer  of  fibrous  tissue,  when  the  pleura  become  thickened 


172  Chaper  XII. 

and  the  fibrosis  spreads  tLrougliout  the  lung.  Fibroid  phthisis 
is  extremely  chronic  in  its  course. 

The  physical  signs  are  those  of  shrinking  of  the  affected 
lung  with  some  compensatory  emphysema  on  the  oj)posite  side. 
Signs  of  cavity  may  be  apparent,  indicating  either  the 
presence  of  an  old  cavity,  the  result  of  previous  softening,  or 
the  dilatation  of  a  bronchus  secondary  to  the  shrinking  of  the 
lung.  When  the  cavity  is  bronchiectatic  expectoration  is  apt 
to  be  profuse  and  foetid.  Cough  is  troublesome  and  may  be 
paroxysmal  in  character.  Oedema  of  the  legs  and  feet  may 
result  from  failure  of  the  right  heart,  and  amyloid  degenera- 
tion of  the  kidney,  spleen  or  liver  may  occur  from  the  long- 
continued  suppuration  in  a  cavity  or  in  dilated  bronchi. 

Complications. —  All  the  viscera  may  become  infected  by 
the  bacillus  of  tubercle  during  the  course  of  pulmonary 
phthisis.  Tuberculous  ulceration  of  the  larynx,  and  of  the 
mouth,  tongue  and  gastro-intestinal  tract  generally  may  take 
place.  A  tuberculous  meningitis  may  occur,  and  tuberculosis 
of  the  liver,  spleen  and  kidneys  are  met  with  as  the  result  of 
a  generalised  tuberculous  infection  secondary  to  a  lesion  in 
the  lung  and  bronchial  glands.  Tuberculous  pyosalpinx  is 
not  uncommon  among  women  in  advanced  stages  of  pulmonary 
phthisis,  and  tuberculosis  of  the  bladder  and  testicle  may 
also  occur.  Degeneration  of  the  cardiac  muscle  and  thicken- 
ing of  the  pulmonary  artery  are  frequently  met  with,  and  in 
the  later  stages  of  the  disease  a  rapid  feeble  pulse  with  dysp- 
noea which  is  exaggerated  on  exertion  is  very  common.  In  such 
cases  apical  and  basal  systolic  murmurs  are  audible,  usually 
without  any  valvular  lesion  being  present.  Loss  of  appetite 
and  pain  or  discomfort  after  food  are  often  extremely  trouble- 
some and  hinder  treatment.  Diarrhoea  is  frequently  a  serious 
complication  even  early  in  the  disease  but  is  more  common  in 
the  later  stage,  due  to  ulceration  of  the  ileum  with  concomitant 
catarrh,  or,  in  some  instances,  to  amyloid  degeneration  of  the 
mucous  membrane. 

Haemoptysis  may  occur  late  or  early  in  the  disease.  When 
early,  it  is  not  in  itself  dangerous,  although  it  may  be  severe 
and  prolonged,  but  when  it  appears  as  a  late  occurrence,  in 
connection  with  cavity-formation  or  a  fibroid  condition  of  the 


Pulmonary  Tuberculosis.  173 

lung  it  may    be  extremely    Juiig-erous  und    is   not  infrequently 
fatal. 

Diagnosis. — The  diagnosis  of  pulmonary  consumption 
depends  very  largely  in  most  cases  on  the  discovery  of 
jjhysical  signs,  and,  as  the  patient  usually  presents  himself 
in  the  early  stages  of  the  disease,  these  may  be  slight  and 
limited.  A  little  deficiency  in  expansion  in  one  or  other 
apex,  with  diminution  in  the  volume  of  the  respiratory  mur- 
mur and  a  little  impairment  of  the  percussion  note  may  be 
fill  that  there  is  to  indicate  the  lesion,  and  in  no  department 
of  clinical  medicine  do  finesse  and  accuracy  tell  so  much  as  in 
the  detection  of  an  early  lesion  in  phthisis.  The  slightest 
variations  from  the  normal  in  expansion  of  the  chest  and  in 
the  results  of  auscultation  and  percussion  should  be  carefully 
noted,  and  the  sputum  should  be  examined  in  every  suspicious 
case.  In  certain  cases  the  detection  of  bronchial  breathing, 
with  or  without  moist  crepitations  or  occasional  clicking  rales, 
together  with  slight  but  definite  dullness  on  percussion  make 
the  diagnosis  easy  w^hen  combined  with  the  history  of  the 
case  and  study  of  the  temperature.  In  other  cases,  however, 
although  they  have  suffered  from  cough  and  certain  constitu- 
tional disturbances,  the  most  careful  examination  by  a  com- 
petent physician  may  fail  to  reveal  the  presence  of  any  phy- 
sical signs,  and  the  diagnosis  may  be  arrived  at  only  after 
careful  study  of  the  history  and  temperature  and  examination 
of  the  sputum.  In  many  cases  the  occurrence  of  a  pleurisy, 
with  or  without  effusion,  is  tlie  first  incident  in  the  patient's 
illness,  and  the  detection  of  a  pleurisy  in  a  young  person 
should  always  arouse  in  the  mind  of  the  physician  the  sus- 
picion that  it  may  be  of  tuberculous  origin.  Haemoptysis, 
severe  or  slight,  may  be  the  first  circumstance  which  draws  the 
patient's  attention  to  the  state  of  his  health,  and  is,  in  the 
absence  of  any  obvious  lesion  in  the  heart,  nasopharynx  or 
pharynx,  very  suggestive  of  early  phthisis.  A  catarrhal  con- 
dition of  the  lung  which  becomes  limited  and  unilateral  and 
does  not  clear  up  in  a  few  weeks  should  make  the  physician 
careful  to  exclude  the  possibility  of  its  being  the  result  of  an 
infection  by  the  B.  tulDerculosis.  Most  patients  give  a  history 
of  general  deterioration  in  health,  a  cough  which,  although 


174  CJiapter  XII. 

perhaps  not  severe,  will  not  yield  to  ordinary  treatment,  some 
loss  of  appetite  and  dyspepsia  with  more  or  less  pallor  and, 
tbe  most  common  part  of  the  story,  distinct  loss  of  weight, 
sometimes  very  marked.  There  is  frequently  a  history  of 
sweating  at  night,  and  some  pain  in  the  upper  part  of  the 
chest.  All  young  subjects  who  suffer  from  chronic  dyspepsia, 
persistent  slight  auEemia,  and  rapid  and  unexplained  loss  of 
weight,  should  be  most  carefully  examined  for  signs  of  tuber- 
culosis, and  no  examination  is  complete  without  the  careful 
and  repeated  examination  of  the  sputum  for  the  bacillus  of 
tubercle  and  a  systematic  observation  of  the  temperature, 
especially  after  exercise  in  the  afternoon.  Many  patients  wdth 
no  physical  signs  suggestive  of  phthisis  but  who  suffer  from 
one  or  more  of  the  symptoms  just  described  will  be  found  to 
have  a  distinct,  if  slight,  rise  in  temperature  each  afternoon 
or  evening,  and  may  have  the  bacilli  of  tubercle  in  their 
sputum  in  considerable  numbers.  One  negative  examination 
of  sputum  is  not  sufficient  to  exclude  the  possibility  of 
phthisis,  indeed  even  repeated  negative  examinations  are  not 
enough  for  the  physician  of  experience.  It  is  far  better  to 
treat  on  suspicion  than  to  wait  for  absolutely  definite  evidence, 
especially  as  many  cases  who  have  been  ailing  for  long  with 
indefinite  symptoms,  having  no  definite  signs  in  the  chest  and 
no  bacilli  in  the  sputum,  may  suddenly  present  all  the  signs 
of  a  rapidly  advancing  phthisis,  and  in  such  cases  the  end 
often  comes  with  startling  rapidity.  In  children,  the  sputum 
is  difficult  to  obtain,  and  when  they  cannot  be  made  to  expec- 
torate, coughing  should  be  induced  by  putting  the  finger 
deeply  into  the  mouth,  and  the  mucus  adhering  to  it  should 
be  examined  for  bacilli  on  withdrawal.  It  is  of  the  utmost 
importance,  for  purposes  both  of  diagnosis  and  prognosis,  that 
the  history  of  a  case  suspected  of  phthisis  pulmonalis  should 
be  carefully  ascertained,  A  predisposition  to  phthisis  is  un- 
doubtedly hereditary,  and  while  all  hereditary  predisposi- 
tions can  be  modified,  and  many  can  be  eradicated,  by  environ- 
ment, it  is  a  matter  of  common  experience  that  a  bad  family 
history  is  a  serious  handicap  to  a  patient  with  consumption, 
and  a  valuable  aid  to  the  diagnosis  of  latent  pulmonary 
tuberculosis. 


Pulmonary  Tuberculosis.  175 

In  examining  the  cliest  of  a  patient  suspected  ol  phthisis, 
the  physician  ought  to  remember  that  next  to  the  upper  hjbe 
the  apex  of  the  lower  lobe  is  the  most  usual  place  for  the 
physical  signs  of  the  disease  to  make  their  first  appearance. 

The  X-rays  are  a  powerful  aid  in  the  diagnosis  of  I)m1- 
monary  tuberculosis. 

The  production  of  a  general  reaction  by  the  use  of  tuber- 
culin has  been  recommended  for  diagnostic  purposes  in 
doubtful  cases,  and  while  many  believe  that  the  practice  i& 
scarcely  justifiable,  I  have  never  seen  bad  results  follow  on 
the  use  of  the  old  tuberculin  if  it  is  given  in  doses  of  ttttttt  c.c. 
as  an  initial  doee.  Calmette's  reaction  is  advocated  by 
some,  but  as  in  some  cases  a  serious  inflammation 
of  the  eye  has  been  the  result  of  the  procedure,  it  is  not  to 
be  strongly  recommended.  Yon  Pirquet's  skin  reaction  is 
frequently  of  service. 

Treatment.  —The  medical  treatment  of  no  disease  has  under- 
gone so  much  modification  in  the  past  twenty  years  as  that  of 
phthisis.        The   realisation   that   many   cases    of   pulmonary 
consumption  proceed  to  spontaneous  cure  has  led  to  the  general 
adoption  of  the  "  open  air  "  and  ''  climatic  "  forms  of  treat- 
ment, which  have  for  their  object  the  improvement  of  the 
patient's   general   condition   by    "fresh    air   and   good   food," 
thus  increasing  his  resistance  to  the  disease,  and  which  have 
raised  so  many  hopes  in  the  minds  of  consumptives.     What 
the  outlook  of  a  patient  suffering  from  pulmonary  tuberculosis 
was  in  early  Victorian  days  can  be  realised  from  the  descrip- 
tion   given    in    "Nicholas    Nickleby."      "There    is    a    dread 
'disease,"    writes    Charles   Dickens,    "that   so    prepares   its 
'  victim,    as   it  were,   for   death ;    which   so   refines   it  of   its 
'  grosser  aspect,  and  throws  around  familiar  looks  unearthly 
'indications    of    the    coming    change;    a    dread    disease,    in 
'  which  the   struggle  between  soul  and  body  is  so  gradual,. 
'  quiet,  and  solemn,  and  the  result  so  sure,  that  day  by  day, 
'  and  grain  by  grain,  the  mortal  part  wastes    and    withers 
'  away,  so  that  the  spirit  grows  light  and  sanguine  with  its 
''  lightening  load,  and,  feeling  immortality  at  hand,  deems  it 
'  but  a  new  term  of  mortal  life ;  a  disease  in  which  death  and 


ITG  Chapter  XII. 

*'  life  are  so  strangely  blended,  that  death  takes  on  the  glow 
■"  and  hue  of  life,  and  life  the  gaunt  and  grisly  form  of  death ; 
■"  a  disease  which  medicine  never  cured,  wealth  never  warded 
■"off,  or  poverty  could  boast  exemption  from;  which  some- 
■*'  times  moves  in  giant  strides,  and  sometimes  at  a  tardy 
"sluggish  pace,  but,  slow  or  quick,  is  ever  sure  and  certain." 
These  are  the  words  of  a  layman  and  a  man  prone  somewhat 
to  dramatic  exaggeration,  but  the  substance  of  the  passage  is 
true  in  the  main,  and  the  attitude  towards  phthisis  up  till  the 
last  quarter  of  the  nineteenth  century  was  one  of  hopelessness, 
and  every  quack  with  a  new  nostrum  was  always  sure  of  a 
clientele.  Since  then,  however,  the  treatment  by  fresh  air 
and  reasonable  feeding  has  changed  the  attitude  of  the  patient 
and  the  physician  alike,  and  the  results  obtained  in  sanatoria, 
lioth  at  home  and  abroad,  seem  to  warrant  a  hopeful  attitude 
towards  the  disease.  The  early  days  of  sanatorium  treatment 
-vrere  rendered  ridiculous  by  the  inclusion  among  the  therapeutic 
measures  of  an  over-feeding  so  gross  that  those  of  strong 
stomach  who  could  tolerate  an  overloading  which  was  nothing 
short  of  disgusting  grew  fat  and  unwieldy,  and,  while  they 
put  on  that  weight  which  was  supposed  to  be  the  great  indica- 
tion of  betterment,  showed  in  eyerj  other  way  that  they  had 
acquired  little  added  powers  of  resistance  and  broke  down  in 
lare-e  numbers  when  sent  back  to  face  life  once  more  at  home. 
No  more  ridiculous  statement  has  ever  been  made  in  medical 
literature  than  that  if  a  patient  grows  fat  the  disease  may 
be  considered  as  a  negligible  quantity.  It  is  greatly  to  the 
credit  of  Huggard  of  Davos  that  he  stood  out  against  over- 
feeding and  looked  upon  an  increase  of  weight  above  the 
patient's  normal  as  no  favourable  sign.  At  the  present  day 
over-feeding  has  largely  slipped  out  of  the  treatment  of 
phthisis  and  much  more  stress  is  laid  on  other  things.  Gradu- 
ated exercise  as  introduced  by  physicians  in  continental  sana- 
toria and  health  resorts  has  been  developed  lately  by  Paterson 
of  Frimley  to  a  great  degree  of  perfection  and  his  results  are 
most  encouraging,  indeed  surprising.  Excessive  feeding  has 
no  place  in  his  programme,  and  his  patients  receive  just  as 
much  food  as  is  necessary  for  the  work  which  they  are  doing. 
The  general  principles  which  underlie  the  modern  treatment  of 


Pulmonary  Tuberculosis.  177 

pulmonary  tuberculosis  are  these — the  putting  of  a  patient 
under  as  good  hygienic  conditions  as  possible  as  regards 
fresh  air,  food  and  cleanliness,  and  helping  him  to  acquire  an 
immunity  against  the  B.  tuberculosis,  so  that  his  tissues  may 
be  able  to  bring  about  that  cure  of  the  disease  with  cicatrisa- 
tion of  the  infected  foci  which,  as  the  study  of  lungs  j)ost 
mortem  has  shown  us,  takes  place  so  frequently  even  under 
most  unfavourable  circumstances.  Paterson's  work  has  made  it 
clear  that,  although  the  local  lesions  may  not  entirely  dis- 
appear, it  is  possible  to  raise  the  immunity  of  the  patient  so 
much  by  exercise  of  a  suitable  kind  that  he  may  be  able  to 
do  work  without  discomfort  and  without  constitutional  dis- 
turbance in  spite  of  the  existence  of  the  local  lesion,  indicating 
that  although  the  bacilli  may  be  present  in  the  lung,  they 
have  sunk  to  the  level  of  mere  saprophytes,  so  far  as  the  pro- 
duction of  symptoms  is  concerned.  To  have  the  patient  in  as 
clean  an  atmosphere  as  possible  is  one  of  the  important  parts 
of  the  treatment,  and  much  wind,  damp,  and  dull  depressing 
weather  are  adverse  climatic  influences.  It  was  because  the 
high  Alpine  climates  fulfilled  these  conditions,  because  their 
atmosphere  was  still  and  exhilarating  and  their  hours  of  sun- 
shine more  numerous  than  in  any  part  of  Great  Britain,  and 
because  they  were  far  removed  from  the  contamination  of 
manufacturing  towns,  that  their  reputation  as  health-resorts 
for  consumptives  stood  so  high.  But  their  altitude  is  to  many 
a  great  disadvantage,  while  the  cold  snow-atmosphere  is 
unfavourable  to  those  who  suffer  from  bronchitis  or  laryngeal 
tubercle,  and  within  the  last  ten  years  sanatoria  have  sprung 
up  in  many  parts  of  the  British  Islands  which  have  given 
results,  perhaps  not  so  good  as  those  to  be  obtained  in  better 
climates,  but  sufficiently  good  to  show  that  the  modern  treat- 
ment is  far  in  advance  of  the  old.  In  the  great  majority  of 
cases  the  life  of  the  patient  is  prolonged  and  rendered  more 
comfortable,  while  his  training  in  the  knowledge  of  the  infec- 
tivity  of  the  disease  and  in  the  best  methods  of  prophylaxis, 
has  greatly  reduced  the  danger  of  his  presence  in  the  com- 
munity. But  the  disadvantages  of  the  ordinary  sanatorium 
treatment  soon  became  apparent.  While  a  certain  drag  was  put 
on  the  disease,  while  physical  signs  disappeared  and  patients 

N 


178  Chapter  XII. 

were  able  to  return  to  their  native  places  in  better  state  than 
when  they  left,  the  habits  of  invalidism  were  strong  in  them, 
and  they  had  for  the  most  part  acquired  a  timidity  in  resuming 
work,  a  timidity  which  was  greatly  justified  by  the  breakdown  of 
so  many  who  tried  to  take  up  work  again  as  usual.  Something 
was  wanting.  Although  the  disease  was  arrested,  the  slightest 
overstepping  of  rules  resulted  in  most  cases  in  at  least  a  partial 
recurrence  of  symptoms,  and  it  became  evident  that  the 
patient  dismissed  from  the  sanatorium  as  "  cured  "  was  still 
among  the  ranks  of  the  unfit.  After  a  struggle  for  a  time 
against  ill-health  the  break-down  came  again,  and  the  patient 
had  to  retire  from  active  life  and  live  once  more  for  his  health. 
When  he  was  a  man  of  means,  who  could  provide  for  his 
family  and  still  live  abroad  or  in  favourable  climates  at  home, 
his  case  was  not  so  hard,  but  when  he  had  no  private  means 
and  depended  entirely  on  his  daily  work  for  a  living  and  for 
the  means  to  support  his  family,  his  condition  w^as  not  only 
a  tragedy  to  himself  and  his  immediate  dependents,  but  a 
burden  to  the  community  in  which  he  lived.  Parish  relief 
was  necessary  in  some  form  or  other  both  for  himself  and  his 
family,  and  his  use  as  a  wage-earner  was  gone.  It  was  evident 
that  the  immunity  acquired  by  rest,  fresh  air,  and  gentle, 
more  or  less  regulated,  exercise  was  not  enough,  in  the 
majority  of  cases,  to  allow  a  man  to  do  full  work  and  preserve 
his  health.  The  work  of  Wright  brought  new  light  to  bear  on 
the  subject  of  acquired  immunity  and  has  made  it  possible  to 
use  inoculation  and  auto-inoculation  as  most  useful  aids  to  the 
"open-air"  treatment  of  pulmonary  phthisis.  Tuberculin 
rightly  used,  and  exercise  properly  supervised  and  regulated, 
have  brought  new  hope  to  those  who  had  been  bitterly  dis- 
appointed by  the  results  of  treatment  merely  by  "fresh  air 
and  good  food." 

All  patients  suffering  from  phthisis  should  be  put  to  bed 
at  once,  and  careful  observations  made  of  their  temperature. 
It  is  usual  to  find,  even  in  early  cases  of  the  more  chronic 
type,  that  the  temperature  is  somewhat  raised,  the  fever  being 
of  a  remittent  or  an  intermittent  type  with  a  morning  reading 
of  nearly  normal  or  normal,  and  a  rise  in  the  afternoon  to  a; 


Pulmonary  Tuberculosis.  179 

register  that  is  subfebrile  or  febrile.  The  temperiituic  sfiould 
always  be  taken  at  4,  G  and  8  p.m.,  so  as  to  be  certain  tli;it  lite 
evening  rise  is  not  being  missed,  if  there  is  fever,  the  patient 
must  be  treated,  as  in  enteric  fever,  by  absolute  rest  and  not 
permitted  to  do  anything  for  liimself.  Absolute  rest  ought 
to  be  maintained  until  the  evening  temperature  has  been 
normal  for  a  few  days,  and  the  patient  begins  to  feel  better 
and  stronger.  At  the  end  of  that  time  he  may  be  allowed  to 
get  up,  at  first  only  in  the  afternoons,  and  in  a  few  days,  if  no 
febrile  disturbance  follows  this  move,  he  should  go  for  a 
slow  walk  of,  say,  half-a-mile  on  the  level.  If  he  is  fairly 
vigorous  and  has  no  fever  within  an  hour  after  his  walk,  the 
walk  should  be  extended  after  three  or  four  days  to  a  mile, 
and  again  to  a  mile  and  a  half  and  again  after  some  days  to 
two  miles,  while  into  the  extended  walk  should  be  introduced 
a  mild  incline  to  make  the  patient  do  actual  work  against 
gravity.  The  pace  should  be  steady,  slow  and  deliberate,  and 
no  hurrying  should  be  allowed.  If  a  severe  reaction  occurs,  afj 
shown  by  a  feeling  of  malaise  and  chill,  with  fever  which  does 
not  disappear  within  an  hour  after  exercise  has  ceased,  abso- 
lute rest  must  again  be  enforced  and  only  after  all  fever  has 
disappeared  should  the  patient  be  allowed  to  walk  again.  If 
no  severe  reaction  occurs  the  next  move  is  to  make  the  patient 
walk  carrying  a  small  quantity  of  earth  in  a  basket  from  one 
place  to  another  and  then  empty  it,  going  back  with  the  empty 
basket  for  more  earth,  always  taking  care  to  be  deliberate 
and  slow  in  all  movements.  The  amount  of  weight  carried 
should  be  carefully  increased  until  the  patient  can  carry  and 
empty  out  baskets  filled  with  several  pounds  of  earth  for 
six  or  seven  hours  in  the  day.  His  next  work  ought  to  be 
trimming  wood  with  an  axe,  followed  by  using  a  lawn  mower. 
Cross-cut  sawing  may  then  be  attempted,  after  which  he  should 
begin  to  shovel  light  earth,  the  size  of  the  shovel  being  care- 
fully graduated  to  his  capacity,  and  the  final  kind  of  work 
should  be  the  use  of  the  pick,  taking  care  that,  at  least  at  the 
commencement  of  the  work,  his  movements  should  be  regular 
and  not  over-active.  Such  is  a  rough  outline  of  Paterson's 
method  of  treatment  as  carried  out  by  him  at  Frimley,  and 
his  results  would  seem  to  fully  justify  his  faith  in  it.     If  the 

N      2 


180  Chapter  XII. 

patient  has  a  severe  reaction  at  any  stage  of  the  treatment,  he 
is  at  once  put  back  to  absolute  rest.  After  all  fever  has  dis- 
appeared, he  is  brought  back,  after  a  couple  of  days  out  of  bed 
without  exercise,  to  a  day  or  two's  mild  walking,  and  is 
then  put  straight  on  to  the  work  at  which  he  broke  down.  It 
will  be  seen  at  once  that  the  principle  involved  in  this  method 
of  treatment  is  one  of  auto-inoculation,  and  the  object  is  to 
produce  by  work  a  reaction  that  is  within  the  patient's  powers 
of  endurance.  If  a  severe  reaction  occurs  it  shows  that  the 
auto-inoculation  has  been  too  great,  and  a  period  of  rest  must 
follow.  When,  however,  the  reaction  has  subsided,  it  is  not 
necessary  to  work  up  slowly  again  to  the  point  at  which  the 
severe  reaction  has  occurred,  but  work  may  be  resumed  at  the 
point  up  to  which  tolerance  has  been  educated.  One  of  the 
great  advantages  of  this  method  of  treatment  is  that  the 
patient  is  receiving  inoculation  b}^  the  toxins  of  his  own 
bacilli,  which  is  known  to  be  an  important  point  in  successful 
vaccine-therapy,  but  the  results  which  Paterson  obtains  at 
Frimley  may  possibly  be  obtained  for  the  many  who  are  unable 
to  be  treated  there  by  a  system  of  graduated  exercise,  even 
when  there  is  no  opportunity  for  the  use  of  the  axe,  saw, 
shovel  and  pick,  combined  with  the  use  of  tuberculin.  The 
great  disadvantage  of  the  human  tuberculin  at  present  avail- 
able seems  to  me  to  be  that  it  is  a  vaccine  obtained  after  the 
passage  of  the  B.  tuberculosis  through  an  animal  and  not  made 
from  bacilli  cultivated  directly  from  human  beings.  Twort  has 
shown  that  the  bacillus  of  tubercle  can  be  easily  cultivated 
directly  from  the  sputum,  on  suitable  media,  and  if  a  vaccine 
were  able  to  be  made  from  the  particular  organism  infecting 
each  patient  directly  from  their  sputum,  it  is  probable  that 
vaccine-therapy  in  pulmonary  tuberculosis  might  give  much 
better  results  than  at  present.  We  do  not  know  what  altera- 
tion takes  place  in  the  virulence  of  the  B.  tuberculosis  dur- 
ing its  passage  through  an  animal,  but  that  some  alteration 
does  take  place  is  extremely  likely.  Even  at  the  present, 
however,  the  careful  use  of  tuberculin  has  given  good  results 
in  the  hands  of  many  physicians.  It  is  usually  injected 
hypodermically,  but  Latham  has  obtained  encouraging  results 
after  its  administration  by  the  mouth. 


Pulmonary  Tuberculosis.  181 

Methods  of  u.nn<j  Tuberculin. — Several  kinds  of  tuber- 
culin are  in  the  market,  O.T.  (the  orig-inal  tuberculin  of 
Koch)  P.T.O.  (a  dilute  bovine  tuberculin),  P.T.  (a  stronger 
bovine  tuberculin),  T.R.  (the  new  tuberculin  of  Eoch),  and 
B.E.  (a  bacillary  emulsion).  Of  these,  T.E.  and  B.E.  are  the 
most  commonly  used,  the  latter  being  said  to  be  particularly 
effective  in  chronic  febrile  cases. 

Camac  Wilkinson  begins  treatment  by  the  injection  of 
P.T.O. ,  working  up  to  P.T.,  and  finally  using  T.R.,  in  care- 
fully graduated  doses.  He  recommends  employing  an  initial 
dose  of  "001  c.c.  of  P.T.O.,  increasing  on  the  next  occasion  to 
'0015  c.c,  and  thereafter  increasing  the  dose  by  doubling  the 
penultimate  dose.  The  patient  should  be  seen  at  least  twice 
a  week,  preferably  three  times.  In  Dr.  Mackenzie's  out-patient 
department  at  Mount  Vernon  Hospital  and  at  the  Margaret 
Street  Hospital  for  Consumption  we  (McClure  and  Barcroft) 
have  been  employing  the  methods  of  Wilkinson  for 
some  two  years  past,  and  have  seen  the  patients  twice 
in  the  week.  In  this  method  the  dose  is  governed 
entirely  by  the  reaction  to  the  injection  which  patients 
present,  and  no  patients  who  show  a  temperature  of 
over  99 '6°  at  any  part  of  the  day  are  considered  suitable  for 
treatment.  The  patient's  temperature  is  studied  carefully 
for  a  week,  being  taken  thrice  daily,  at  8  a.m.,  4  p.m.,  and 
8  p.m.,  and  if,  during  that  week,  no  febrile  movement  has 
occurred  beyond  the  above-mentioned  limits,  treatment  is 
begun,  or,  if  there  be  a  doubt  as  to  diagnosis,  a  test  injection 
of  *001  c.c.  of  O.T.  is  given.  If  after  an  injection  there  has 
been  a  definite  reaction-temperature,  or  very  severe  local  re- 
action, a  dose  is  omitted  and  on  the  nest  visit  the  previous  dose 
is  repeated.  If  on  this  occasion  there  is  no  reaction-tempera- 
ture, or  only  a  very  modest  one,  the  method  of  doubling  the 
penultimate  dose  is  resumed,  and  continued  until  another 
severe  reaction  necessitates  a  similar  pause.  If  a  patient 
shows  great  susceptibility  to  the  tuberculin,  it  is  well  to  give 
half  the  dose  at  which  the  patient  has  broken  down 
three  times  a  week,  then  give  the  dose  to  which  the 
patient  has  shown  himself  susceptible,  and,  should  no 
reaction    occur,     proceed    with     the     series     as    before.       In 


182  Chapter  XI 1. 

this  way  a  patient  who  bas  repeatedly  jibbed  at  the  same 
fence  may  be  tempted  past  it  quite  safely.  Dosage  is  then 
increased  until  "8  c.c.  of  P.T.O.  has  been  given,  after  which 
treatment  is  begun  with  P.T.,  '01  c.c.  being  the  first  dose. 
As  before, the  next  dose  is*U15  c.c.  of  P.T.,  and  the  treatment  is 
continued  until  "8  c.c.  of  P.T.  has  been  given  as  a  dose,  the 
same  care  being  paid  to  the  reaction  as  before.  Then  "01  c.c. 
of  O.T.  is  given,  and  the  process  continued,  until  an  injection 
of  1  c.c.  of  O.T.  completes  the  series. 

The  whole  success  of  this  method  of  treatment  depends 
on  the  steady  and  regular  increase  of  dosage,  and  the  close 
observation  of  the  patient  two  or  three  times  a  week.  If 
dosage  is  irregular  or  not  increased  as  above  indicated,  it 
seems  likely  that  a  condition  of  hypersensitiveness  may  be  pro- 
duced and  the  patient  may  suffer  harm. 

T.R.  is  commonly  used,  also  in  afebrile  cases,  by  the 
injection  of  27Tnon  ^^  a  milligram  to  begin  with,  and  the 
dose  is  increased  gradually,  twice  a  week,  by  doubling,  in 
the  smaller  doses,  and  increasing  by  half  as  the  dose  gets 
moderately  large.  The  dosage  should  be  worked  up  to  5 
milligrams,  the  same  precautions  regarding  reaction  being 
taken  as  above  described. 

Treatment  by  B.E.  is  done  in  a  precisely  similar  way, 
save  that  the  initial  dose  is  even  smaller,  as  a  rule  -s^^-axs  of 
a  milligram  being  commonly  used.  B.E.  is  of  great  service 
in  the  treatment  of  obstinately  febrile  cases  and  cases  which 
react  too  readily  to  the  other  varieties  of  tuberculin,  while  it 
is  frequently  employed  to  complete  the  treatment  of  a  case 
which  has  had  other  forms  of  tuberculin  in  doses  too  large  to 
warrant  continued  increase,  but  when  the  symptoms  seem  to 
demand  further  treatment. 

The  treatment  of  out-patients  by  means  of  tuberculin  is 
of  great  interest  at  the  present  moment  when  there  is  talk  of 
a  great  increase  in  the  number  of  national  sanatoria  for  the 
treatment  of  consumption.  It  is  very  evident  to  most  people 
who  are  actively  engaged  in  work  among  consumptives  that 
sanatorium  treatment  has  been  found  wanting  in  'many  respects, 
more  especially  if  it  is  conducted  on  old-fashioned  and  "accep- 
ted" lines,  while  the  "dispensary"  system  is  capable  of  much 


i 


Pulmonary  Tuberculosis.  183 

useful  development.  It  would  seem  that  tlie  f^stiiblisliitig  of  dis- 
pensaries at  which  patients  could  be  treated  l)y  tuberculin,  in 
one  way  or  another,  and  from  which  tlie  home  condition  of 
the  sufferers  could  be  supervised,  would  be  a  much  more  effec- 
tive and  economical  way  of  fighting  consumption  thaii  the 
building  at  enormous  exj)ense  of  numerous  sanatoria  that 
might  in  a  short  time  serve  simply  to  act  as  monuments  of  the 
folly  of  the  age.  Sanatoria  will  always  be  necessary  for 
the  isolation  of  advanced  cases  and  the  training  of  the  unin- 
telligent, but  to  rely  on  sanatorium  treatment  as  the  great 
weapon  for  tlie  fight  against  consumption  is  unwise,  both  from 
the  point  of  view  of  medical  knowledge  and  national  finance. 

It  is  not  possible  at  present  to  make  up  one's  mind 
definitely  as  regards  the  relative  efficacy  of  the  various  methods 
of  tuberculin  treatment.  It  is  enough  to  w^atch  carefully  and 
compare  the  results  of  those  who  are  employing  different 
methods  and  take  care  neither  to  praise  nor  to  blame  without 
sufficient  cause.  It  must  be  remembered  that  treatment  by 
tuberculin  ought  not  to  be  attempted  by  any  practitioner 
unless  he  has  obtained  practical  experience  of  the  difficulties 
which  may  arise  in  the  course  of  treatment,  by  working  with 
one  who  has  extensive  practical  and  theoretical  knowledge  of 
the  subject.  In  dealing  with  vaccines  we  are  dealing  with 
remedies  which  may  prove  very  dangerous  in  inexperienced  or 
careless  hands. 

Continuous  inhalation. — Some  physicians  prefer  to  treat 
the  patient  by  the  continuous  inhalation  of  volatile  drugs,  and 
the  result  of  this  form  of  treatment  by  Lees  in  fifty  cases 
appears  in  the  Proceedings  of  the  Royal  Society  of  Medicine 
for  1909  (vol.  3,  part  iii.)  and  in  the  Lancet  of  November  19th, 
1910.  The  inhalation  which  Lees  employs  is  composed  of  car- 
bolic acid  3"?  creosote  3^15  tincture  of  iodine  ^i,  spirit  of 
ether  '^i,  and  spirit  of  chloroform  3ii-  Six  drops  of  this 
solution  are  used  in  the  sponge  of  a  Squire's  oro-nasal  inhaler, 
which  must  be  worn  continuously,  day  and  night,  and  the 
patient  should  be  directed  to  inspire  through  the  mouth  and 
expire  through  the  nose,  the  drops  on  the  sponge  of  the  inhaler 
being  renewed  every  hour  during  the  day  and  twice  or  thrice 
during  the  night  if  the  patient  is  awake.     Lees  states  that 


184  CJiapfer  XII . 

under  this  method  of  treatment  his  cases  showed  marked  im- 
provement, and  25  out  of  his  first  series  of  30  cases  he  regartls 
as  "  cured,"  13  of  them  having  worked  for  upwards  of  a  year 
without  a  relapse.  It  is  difticult  to  see  what  directly  bacteri- 
cidal effect  such  small  quantities  of  antiseptics  can  have,  but 
in  my  own  experience  I  have  found  that  the  use  of  a  somewhat 
similar  inhalation  (equal  part  of  the  aethereal  tincture  of 
iodine,  creosote,  eucalyptus  oil  and  spirit  of  chloroform)  has 
been  of  the  greatest  use  in  subduing  cough  and  lessening 
catarrh,  and  patients  have  made  great  improvement  under  its 
influence.  It  is  probable  that  in  many  cases,  especially  in 
those  which  have  an  acute  onset,  with  a  fair  amount  of 
catarrh  and  considerable  cough,  the  use  of  such  continuous 
inhalations  will  prove  a  valuable  adjunct  to  the  treatment  by 
fresh  air,  exercise  and  tuberculin.  I  have  found  it  necessary 
to  omit  the  creosote  in  certain  cases  because  it  seemed  to  pro- 
duce nausea,  which  disappeared  on  its  withdrawal. 

Treatment  by  the  lyroduction  of  an  artificial  i^neuviothorax. 
— In  certain  advanced  cases  of  phthisis,  when  there  is  much 
expectoration  and  where  the  lesion  is  mainly  unilateral  and 
where,  also,  there  are  no  pleural  adhesions  of  anj-  great  extent 
in  the  affected  side,  the  production  of  an  artificial  pneumo- 
thorax by  puncturing  the  pleural  cavity  and  introducing  N. 
has  been  found  by  some  to  be  of  service,  but  the  operation  is 
not  a  slight  one,  and  ought  not  to  be  undertaken  lightly. 
Opinions,  both  at  home  and  on  the  continent,  vary  greatly  as 
to  the  amount  of  benefit  to  be  derived  from  this  procedure. 

The  gums  and  teeth  of  all  phthisical  patients  must  be  care- 
fully attended  to,  as  oral  sepsis  is  a  very  common  cause  of 
dyspepsia.  Any  nasal  obstruction  should  be  dealt  with,  either 
by  the  cautery  or  by  the  use  of  an  ointment  containing  men- 
thol and  cocaine  in  vaseline,  since  there  is  no  commoner  cause 
of  laryngitis  than  a  chronic  post-nasal  catarrh,  and  mouth- 
breathing  is  to  be  more  than  usually  discouraged  for 
consumptives. 

Cough  is  a  symptom  which  needs  careful  and  diligent 
treatment.  The  influence  of  severe  coughing,  whatever  be  the 
cause,  is  always  adverse  to  the  patient's  progress;  it  destroys 
his  rest,  shakes  him  up,  and  may  induce  vomiting,  particularly 


Pulmonary  7'uhercul.osis.  185 

just  after  food.  One  or  other  of  the  dry  inhalations 
already  mentioned  will  help  towards  its  dissipation,  and  the 
use  of  a  cocaine  and  menthol  ointment  for  the  nose  may  also 
be  beneficial.  Moist  inhalations  are  not  to  be  recommended 
in  phthisis.  When  the  cough  is  connected  with  a  considerable 
amount  of  catarrh  in  the  chest  a  mixture  containing  am- 
monium carbonate  (iii  grains),  spirit  of  chloroform  (xxcminims) 
and  camphor  water  (3ii)  ^^^J  be  used  with  advantage,  while 
if  there  is  any  tendency  to  asthma,  small  doses  of  potassium 
iodide  and  tincture  of  stramonium  are  often  of  great  service. 
The  bromides  frequently  relieve  a  troublesome  spasmodic 
cough.  Sometimes,  however,  in  spite  of  rest,  inhalations  and 
the  above  drugs,  the  cough  does  not  yield,  and  one  is  forced 
to  use  opium  in  some  form  or  another  for  its  alleviation. 
Pinheroin  in  doses  of  a  drachm,  repeated  every  three  or  four 
hours,  is  useful,  and  paregoric  is  also  of  service.  Where  all 
these  fail  it  may  be  necessary  to  give  doses  of  opium  sufficient 
to  induce  sleep,  and  under  these  circumstances  the  hypodermic 
injection  of  ^-^  grain  of  morphine  is  advisable,  rather  than 
the  tincture  of  opium  or  Battley's  solution  by  the  mouth. 

Treatment  of  Complications.— G^astric  dyspepsia  may  be 
relieved  by  the  use  of  sodium  bicarbonate  (grs.  v-x),  the 
heavy  or  light  carbonate  of  magnesium  (grs.  x-xv),  and  the 
carbonate  of  bismuth  (grs.  x-xv)  given  some  fifteen  minutes- 
after  a  meal,  and  the  diet  must  be  carefully  regulated.  Where 
dyspepsia  exists  great  attention  should  be  paid  to  oral  cleanli- 
ness and  to  diet. 

Diarrhoea,  if  at  all  severe,  must  be  treated  by  bismuth 
carbonate  and  pulv.  opii  in  moderately  large  doses  repeated 
at  fairly  frequent  intervals.  The  general  condition  of  the 
patient  and  the  behaviour  of  the  diarrhoea  under  treatment 
must  determine  the  dosage.  At  the  same  time  a  semi-fluid 
diet  of  milk,  milk-puddings  and  bread  should  be  given.  Gentle 
irrigation  of  the  lower  bowel  with  hot  water  has  a  good  effect 
in  checking  diarrhoea  in  certain  cases. 

Tuberculosis  of  the  bladder,  kidneys,  and  testicle  must  be 
dealt  with  surgically,  either  immediately,  or  following  on  a 
course  of  treatment  by  tuberculin,  while  a  tuberculous  pyosal- 
pinx  can  be  treated  only  by  surgical  interference. 


186  Chapter  XII. 

Errvpyema  presents  certain  therapeutic  difficulties.  If 
opened  and  drained  it  is  extremely  likely  to  become  chronic, 
and  if  punctured  and  drained  by  cannula,  fluid  is  liable  to 
collect  again  rapidly  and  is  extremely  easily  infected  by 
pyogenic  organisms  after  repeated  puncture.  It  is  wise  to 
leave  a  tuberculous  empyema  alone  as  long  as  is  possible  com- 
patible with  the  safety  and  comfort  of  the  patient,  and  then 
to  have  it  dealt  with  surgically,  at  the  same  time  instituting 
a  suitable  treatment  by  tuberculin. 

For  pneumothorax  and  hydropneuTnothorax  little  can  be 
done  save  in  the  way  of  rest  and  palliation. 

Cardiac  failure  must  be  met  in  the  ordinary  way,  by  hot 
applications  over  the  heart,  hypodermic  injections  of  strych- 
nine and  ether  and  alcohol  by  the  mouth  if  it  be  acute,  while 
if  it  be  gradual,  digitalis  and  strophanthus  may  help  to  ward 
off  the  final  syncope.  The  inhalation  of  oxygen  is  of  use  in 
all  cases  with  failing  heart  where  there  is  much  cyanosis. 

When  hoimoptysis  occurs  the  patient  must  be  kept  most 
rigidly  quiet,  both  physically  and  mentally,  and  morphine 
should  be  given  hypodermically.  The  administration  of  tur- 
pentine by  the  mouth  or  as  an  ingredient  in  a  solution  for 
inhalation  has  many  advocates.  Adrenalin  and  ergotin  are 
of  little  value.  The  application  of  ice  to  the  chest  is  recom- 
mended, but  if,  as  is  usual,  it  makes  the  patient  fretful,  it 
does  more  harm  than  good.  Calcium  chloride  has  been  given 
with  a  view  to  increasing  the  coagulability  of  the  blood. 

Laryngeal  tuherculosis  should  be  treated  by  absolute  rest 
of  the  voice — the  patient  should  not  be  allowed  to  utter  a 
single  word,  for  weeks,  if  necessary,  or  even  months — by  the 
use  of  continuous  dry  inhalations,  and  by  puncture  of  the 
swellings  about  the  cords  and  of  the  ulcerated  areas,  by  the 
galvano-cautery.  Cough  must  be  subdued,  by  opium  if  need 
be.  A  mild  "  island  climate  "  like  Capri,  the  Grand  Canary, 
Teneriffe,  Madeira,  or  the  south-west  of  England  and  the 
Channel  Islands  is  most  suitable  for  those  who  suffer  from 
laryngeal  tubercle.  The  cold  of  high  altitudes  is  distinctly 
against  their  progress. 

When  there  is  much  anosTnia,  the  condition  may  be  helped 
by  the   administration   of  iron  and  arsenic  when   no  gastric 


Fuhnonary  7'uherculo.si.s.  187 

discomfort  follows  on  their  use.  Otherwise  it  is  well  to  let 
the  ansemia  take  care  of  itself,  realising  that  as  the  patient 
grows  able  to  overcome  the  infection  it  will  improve. 

Diet. —  During  the  febrile  stage  of  pulmonary  tubercu- 
losis the  diet  should  consist  mainly  of  fluids,  milk  puddings, 
bread  and  butter,  fish  and  eggs,  the  proportion  of  fluids  to 
solids  varying  in  accordance  with  the  severity  of  the  fever. 
Unless  diarrluea  is  troublesome  the  patient  even  when  there 
is  considerable  fever  can  tolerate  a  semi-fluid  dietary  of  fairly 
generous  proportions.  It  must,  of  course,  be  limited  by  the 
toleration  of  the  patient,  and  dyspepsia  and  nausea,  which 
are  frequent  results  of  an  over-loading  of  the  stomach,  should 
be  avoided  if  possible,  and,  when  they  do  occur,  must  be 
treated  with  care.  AVhen  there  is  no  fever,  and  appetite  is 
good,  a  generous  diet  is  advisable,  which  should  contain  a 
considerable  proportion  of  fat,  in  the  shape  of  butter,  bacon 
fat,  and  milk.  Milk  should  always  be  "  scalded  "  before 
being  given,  as  in  the  present  state  of  our  milk-supjjly  it  may 
prove  an  easy  way  of  adding  to  the  infection  from  which  the 
patient  suffers  if  it  is  taken  uncooked.  Generally  speaking,  a 
pint  or  two  of  milk  should  be  added  to  the  patient's  ordinary 
dietary,  bacon  should  be  eaten  frequently  with  breakfast,  and 
butter  ought  to  be  used  freely.  In  other  respects  the  diet 
should  be  as  reasonably  ample  as  the  patient's  means  permit, 
and  must  conform  to  his  personal  likes  and  dislikes.  Sanatogen 
and  other  proprietary  preparations  are  sometimes  of  service  in 
neurotic  cases,  and  raw  meat  juice  or  sandwiches  of  raw  meat 
are  useful  when  there  is  considerable  dyspepsia  and  anaemia. 
It  must  be  remembered  that  Paterson  gets  his  excellent  results 
in  patients  who  are  doing  w-ork  on  a  diet  which  is  within  the 
means  of  an  ordinary  working  man.  In  any  case  it  is  better 
to  give  three  good  meals  a  day  unless  the  patient  is  so  feeble 
as  to  require  frequent  small  meals,  so  as  to  give  the  stomach 
a  chance  of  emptying  itself  properly  between  meals.  If  milk 
is  not  borne  well,  a  little  meat  extract  given  half-an-hour 
before  will  often  ensure  its  tolerance. 

Epidemiology. —  Pulmonary  tuberculosis  may  be  said  to  be 
endemic  in  every  country  which  can  boast  of  an  advanced 
civilisation,  and  it  has  been  spread  almost  all  over  the  world 


188  Chapter  XII. 

b}'  the  agency  of  those  Avho  have  gone  from  civilised  to  un- 
civilised parts,  at  the  call  of  business  or  pleasure.  Its  worst 
manifestations  are,  of  course,  found  in  those  countries  where 
a  cold  and  damp  climate  predisposes  to  all  catarrhal  affections, 
and  particularly  where  the  presence  of  large  manufacturing 
centres  encourages  overcrowding  and  makes  poverty  squalid 
and  unclean.  All  occupations  where  people  are  exposed  to 
foul  dust-laden  air  predispose  to  the  acquirement  of  the 
disease,  and  packers  in  dry  goods  stores,  steel-grinders,  stone- 
masons, sempstresses  in  large  warehouses  and  workers  in 
asbestos  factories,  etc.,  are  all  more  than  ordinarily  liable  to 
the  disease.  In  short,  any  conditions  of  work  and  life  which 
involve  dust-breathing,  overcrowding,  and  all  the  plwsical 
deterioration  consequent  on  small  wages,  insufficient  food  and 
poor  lodging,  are  the  causes  which  above  all  others  favour  the 
acquirement  of  pulmonary  tuberculosis.  Considering  how 
common  such  conditions  are,  and  how  widely  spread  in  our 
streets,  houses  and  food  the  infecting  organism  must  be,  it 
is  less  surprising  that  so  many  people  contract  phthisis  than 
that  so  many  escape. 

Method  of  Infection. — It  is  now  generally  recognised  that 
the  commonest  method  of  infection  is  by  the  ingestion  or 
inhalation,  by  the  taking  into  the  mouth  or  nose,  of  the  B. 
tuberculosis  contained  in  dust  contaminated  hj  the  discharges 
of  infected  persons.  I  do  not  propose  to  discuss  the  merits  of 
the  inhalation  and  ingestion  theories,  but  it  seems  likely  that 
the  bacillus  gains  entry  in  many  cases  by  the  adenoid  tissue  of 
the  tonsils  and  nasopharynx,  while  in  other  cases  it  may  be 
swallowed  and  may  enter  by  some  part  of  the  intestinal  tract. 
Animal  experiments  have  shown  that  the  entry  of  the  bacilli 
through  the  intestine  may  produce  a  pulmonary  lesion  without 
the  formation  of  any  gross  lesion  in  the  abdomen. 

Milk  infected  by  the  bacillus  of  bovine  tuberculosis, 
whether  in  the  cow  or  in  its  passage  from  the  cow,  or  con- 
taminated by  the  bacillus  of  human  tuberculosis  at  some 
part  of  the  lengthy  and  intricate  journey  which  it  has  to  go 
from  the  cow  to  the  consumer,  is  also  a  fruitful  source  of 
infection.  Direct  contact  with  those  suffering  from  consump- 
tion, through  kissing  or  speaking,  also  plays  some  part  in  the 


Fulmonary  Tuberculosis.  189 

spread  of  the  disease.  Inherited  vulnerability  to  tlie  B.  tuber- 
culosis, occupation,  unhealthy  social  surrounding-s,  insufficient 
"food,  careless  habits  of  life,  and  certain  other  acute  diseases, 
such  as  whooping-cough,  measles,  influenza,  and  pneumonia, 
are  among  the  chief  causes  which  tend  to  render  one  liable  to 
contract  the  disease. 

Period  of  Infectivity. —  It  is  probable  that  a  patient  who 
suffers  from  phthisis  is  infective  for  at  least  as  long  as  his 
sputum  shows  the  presence  of  the  bacilli  of  tubercle,  and  this 
may  be  for  long  after  it  can  be  detected  by  staining  and 
microscopical  examination,  but  when  it  is  present  only  ia 
such  small  numbers  that  its  detection  is  very  difficult  or  im- 
possible, the  infecting  power  of  the  patient  must  be  very 
small  and,  if  he  exercises  proper  precautions,  quite  negligible. 

Death-rate. —  As  pulmonary  tuberculosis  has  not  been  even 
a  voluntarily  notifiable  disease  until  very  recently,  and  then 
only  in  certain  districts,  it  is  not  possible  to  ascertain  the 
mortality  among  consumptives  with  anything  like  accuracy. 
It  is  probable  that  of  those  who  have  shewn  definite  signs  of 
phthisis  only  a  small  minority  make  a  complete  recovery, 
although  in  a  much  greater  proportion  the  disease  is  arrested 
and  its  course  becomes  so  chronic  and  protracted  that  many 
die  from  causes  only  indirectly  connected  with  their  tuber- 
culous infection,  after  the  lapse  of  perhaps  twenty  or  thirty 
years  from  the  time  of  its  recognition. 

Home  prophylaxis. — Patients  who  remain  at  home  after 
developing  phthisis  ought  to  exercise  very  stringent  precau- 
tions in  their  family  life.  They  ought  to  sleep  in  a  room 
devoted  entirely  to  their  own  use,  which  should  have  no  hang- 
ings or  carpet,  but  which  should  have  the  floor  covered  with 
linoleum,  on  which  may  be  placed,  for  comfort's  sake,  one  or 
two  rugs  of  washable  material  resembling  Turkish  towelling. 
Distemper  should  be  used  instead  of  paper  for  the  walls,  and 
this  should  be  renewed  at  least  once  each  year.  If  there  is 
any  expectoration  it  should  be  disposed  of  in  small  paper 
handkerchiefs  which  ought  to  be  burned  at  once.  The  room 
should  be  well  ventilated  by  open  windows  and  an  open  fire, 
at  least  in  those  countries  where  the  climate  permits  of  heating 
by  this  method.     Radiators  may  take  the  place  of  fires  when 


190  Chapter  XII. 

the  winter  is  too  cold  for  the  rooms  to  be  kept  at  a  reasonable 
temperature    by    the    English    fire.       The    room    should    be 
frequently   disinfected   by   the   formalin   spray   and   formalin 
vapour,  and  all  bed  clothes  and  washable  body-clothing  should 
be  fornialinised  before  being  sent  to  the  wash.     The  formalin 
spray  should  be  used  at  intervals  for  the  disinfection  of  outer 
clothing  worn  by  the  patient  or  stored  in  his  room.        The 
children   of   the   household    should    be  forbidden   to   kiss   the 
patient  or  remain  long  in  close  contact  with  him,  and  especi- 
ally should  they  not  enter  his  bedroom  or  have  him  in  the 
nursery  or  schoolroom.     When  houses  are  not  large  enough  to 
ensure  such  complete  isolation  the  patient  ought  at  least  to 
have  a  bedroom  for  his  own  exclusive  use,  or,  if  he  is  in  the 
country,  he  ought  to  sleep  out  in  a  garden  shelter,  and  avoid 
as  far  as  possible  close  contact  with  the  younger  members  of 
the  family.     Those  who  have  to  be  in  contact  with  patients 
suffering  from  phthisis  or  who  have  a  bad  family  history,  ought 
to  take  special  care  to  preserve  their  health  by  living  in  as  good 
hygienic  surroundings  as  they  can,  and  by  reasonable  exercise, 
regular  hours  and  temperance  in  eating,  drinking  and  smok- 
ing,  should  endeavour  to  keep  their  powers  of  resistance  as 
high  as  possible.     The  proper  ventilation  of  houses  is  most 
important,  and  all  rooms  when  not  occupied  should  have  the 
windows  thrown  widely  open,  except  when  a  fog  settles  down 
over  the  district  in  which  the}^  are  situated,  and  a  window 
should  be  slightly  open  in  every  room  day  and  night  except 
when  raw  damp  weather  prevails.     It  is  true  that  the  bringing 
up    of   children   in   well-ventilated   rooms    is    a   necessity   for 
health,  but  the  habit  of  the  open  window  at  night  should  not 
be   rigid,   especially  with   young   children,    in  towns   and   in 
damp  bleak  districts.     It  is  probable  that  the  constantly  open 
window  during  the  night  has  something  to  do  with  the  pro- 
duction of  chronic  tonsillar  inflammation  and  with  the  forma- 
tion  of   post-nasal   adenoid   growths.      These   conditions   may 
arise  from  quite  different  predisposing  causes,  but  the  bigoted 
routine  of  open  windows  at  night  may  at  least  encourage  their 
occurrence.     In  view  of  modern  ideas  regarding  the  methods 
of  entrance  of  the  B.  tuberculosis,  it  is  of  the  utmost  import- 
ance that  tonsillar  inflammation  and  the  formation  of  post- 


Pulmonary  Tuberculosis.  191 

nasal  adenoids  should  bo  avoided  if  possible  and  promptly 
dealt  with  when  they  arise,  since  an  unhealthy  condition  of 
the  tonsils  and  naso-j)harynx  make  the  attack  of  the  B. 
tuberculosis  much  more  likely  to  be  successful.  The  proper 
feeding  of  children,  instead  of  the  usual  haphazard  fashions  of 
child-feeding  that  obtain  so  generally,  the  care  of  the  mouth 
and  teeth,  the  daily  bath  and  plenty  of  open-air  exercise,  com- 
bined with  scrupulous  cleanliness  of  the  house,  will  do  far 
more  to  build  up  a  child  to  resist  the  attack  of  the  tubercle 
bacillus,  than  the  blind  belief  in  the  necessity  for  the  con- 
tinuously open  window  which  is  made  to  cover  such  a  multi- 
tude of  sins  of  mismanagement  in  other  directions.  The 
Jesuits'  saying  that  if  the  Society  of  Jesus  has  the  control 
of  a  child  till  he  is  seven  years  old  he  will  not  easily  drift 
away  from  them  in  adult  life,  is  wonderfully  true,  and  what 
is  true  mentally  and  morally  of  that  saying  is  equally  true  in 
a  physical  sense  of  the  importance  of  the  first  ten  years  of  a 
child's  life  with  regard  to  his  future  constitution.  The  neg- 
lect or  misdirection  of  exercise,  careless  feeding,  lack  of  care 
of  the  mouth,  bowels  and  teeth,  and  the  failure  to  recognise 
the  slight  symptoms  which  show  some  inherent  peculiarity  of 
metabolism,  may  lay  the  foundation,  before  a  child  is  a  dozen 
years  old,  of  a  constitution  which  will  show  a  resistance  to 
all  disease  much  below  the  normal,  and  may  be  particularly 
vulnerable  to  tuberculosis. 

Public  health  administration.— The  duties  of  the  Local 
Authority  in  respect  of  pulmonary  tuberculosis  are  ill-defined. 
In  those  districts  where  it  is  a  notifiable  disease,  inspection  of 
the  patient's  surroundings  and  reporting  on  the  housing-condi- 
tions and  disinfection  of  houses  are  done,  and  in  a  few  places 
municipal  dispensaries  for  the  out-door  treatment  of  cases  have 
been  opened.  The  value  of  dispensary  work  cannot  be  over- 
estimated. It  enables  the  medical  officer  to  discover  the  dis- 
tricts in  which  phthisis  is  rife,  so  that  special  efforts  can  be 
made  as  regards  the  improvement  of  their  sanitation  and  the 
disinfection  of  infected  dwellings,  while  valuable  instruction 
can  be  given  to  the  patients  as  to  the  best  means  of  making 
them  less  dangerous  to  their  families.  It  is  possible  that  the 
establishment  of  municipal  sanatoria  supported  by  the  rates 


192  Chapter  XII. 

might  be  useful  at  least  as  educative  centres,  eyen  though 
it  might  be  impossible  to  undertake  the  "  cure "  of  many 
cases  owing  to  the  time  and  expense  iuA^olved  and  the  small 
number  that  could  be  dealt  with  in  a  year.  "  The  greatest 
^ood  to  the  greatest  number  "  must  always  be  the  motto  of 
public  health  administration,  and  it  would  be  wrong  to  devote 
a  year  to  one  patient  while  half-a-dozen  others  are  deprived  of 
-even  a  preliminary  course  in  the  sanatorium.  From  the  point 
•of  view  of  the  community  it  is  not  within  the  realms  of  prac- 
tical politics  to  attempt  to  isolate  all  those  who  have  phthisis, 
•on  account  of  their  numbers  and  the  probable  duration  of  their 
treatment,  but  that  more  should  be  done  than  at  present  is 
undoubted.  Private  enterprise  does  a  great  deal,  but  more 
dfree  institutions  are  necessary  if  the  war  is  to  be  waged  satis- 
factorily, considering  how  the  great  majority  of  consumptives 
:are  drawn  from  the  really  poor  classes. 

The  advanced  case,  with  cavity  formation  and  profuse 
•expectoration,  constitutes,  after  the  early  unrecognised  case, 
the  greatest  danger  to  the  community,  and  ought  to  be  strictly 
isolated,  either  at  home  or  in  a  house  in  the  country  when 
means  permit,  or  in  some  institution  under  the  control  of  the 
Parish  Council  or  Local  Authority  where  the  means  of  the 
"family  are  small.  Such  advanced  cases  are  hopeless  as  regards 
cure,  and  sentiment  should  no  more  stand  in  the  way  of  their 
segregation  than  in  the  case  of  lepers,  while  the  expense 
involved  could  with  a  little  thought  be  saved  out  of  certain 
departments  and  buildings  whose  upkeep  and  construction 
are  somewhat  too  costly  as  compared  with  their  usefulness. 
Strict  regulations  about  spitting  in  workshops,  public  places 
and  public  conveyances  ought  to  be  made  and  enforced  with 
rigour.  Much  can  be  done  by  municipalities  and  Borough 
Councils  to  lessen  the  incidence  of  phthisis  by  the  lessening 
■of  dust.  Streets  can  be  paved  with  asphalt,  thus  presenting 
an  impervious  surface  that  can  be  washed  clean  at  least  once 
a  day  and  watered  frequently  in  dry  weather.  Wood  pave- 
ment, and  the  granite  setts  with  which  so  many  of  our 
northern  towns  are  paved,  are  both  insanitary,  especially  the 
latter,  because  not  only  is  the  space  between  the  setts  impos- 
;sible  to  clean  out  thoroughly,  but  the  dust  derived  from  the 


PulTnonary  Tuberculosis.  193 

wearing  of  the  g-ranite  is  peculiarly  irritating  and  likely  to 
encourage  catarrhal  affections  of  the  throat  and  bronchi. 

The  food  supply,  also,  demands  the  attention  of  the  local 
authority.  Meat  is  probably  fairly  safe  as  regards  infection 
by  tuberculosis,  but  the  butter  and  milk-supply  is  still  in  a 
most  unsatisfactory  condition.  The  whole  system,  from  cow 
and  farm  to  the  attendants  in  milk-shops  and  those  who  dis- 
tribute milk  in  our  towns,  needs  careful  consideration,  and 
not  the  least  important  point  is  the  supervision  of  the  health 
and  homes  of  those  who  have  to  do  with  the  retail  trade  in 
food-stuffs. 


O 


(    194  ) 


Chapter  XII L 


DYSENTERY. 

Synonyms :      Fr.  -.       Dysenterie. 
Ger.  :      Dysenteria. 


Definition.  —  The  name  "  Dysentery  "  is  given  to  a  group 
of  symptoms  :  — pain  in  the  abdomen  of  a  colicky  character, 
tenesmus,  and  the  passage  of  frequent  small  slimy  stools,  con- 
taining blood,  associated  with  an  inflammation  of  the  mucous 
membrane  of  the  colon.  The  causal  agents  producing  these 
S3''mptoms  are  various,  and  include  the  Amoeba  dysentericB,  the 
Balantidium,  Coli,  the  Bacillus  .Dysenterioi  of  Shiga,  the 
Billiarzia  H CBmatohium ,  and  the  infecting  organisms  of 
Malaria  and  Kala  Azar.  The  B.  Pyocyaneus  has  also  been 
known  to  produce  dysenteric  symptoms.  It  is  not  usual 
to  describe  the  dysenteric  symptoms  met  with  in  Bil- 
harziosis,  Malaria,  or  Kala  Azar,  under  the  head  of 
'■  dysentery,"  and  the  name  is  usually  given  to  the  diseases 
produced  by  the  Bacillus  dysenteriee  discovered  by  Shiga  in 
1898,  and  by  the  Amoeba  Dysenterise  described  by  Losch  in 
1875,  the  first  being  called  Bacillary  Dysentery,  and  the 
second  Amcehic  Dysentery.  It  is  best  to  describe  them 
separately,  as  they  are  two  separate  and  distinct  diseases,  with 
definite  clinical  as  well  as  causal  differences. 

Bacillary  Dysentery.  —  Incubation,  period  :  The  incubation 
is  short,  probably  about  38  hours. 

Rash. — No  rash  has  been  described  as  typical  of  the 
disease. 


])i).s('nl.('rji.  195 

Clinical  Types. — 4Mio  disease  begins  sutldciily,  willi  sh.jrp 
griping  pain  in  tlie  ubdonnui,  tenesmus,  and  IIk;  passage  of 
small  mucous  stools  tinged  witli  blood.  Tlie  temperature 
rises  to,  say,  101°  1<\  or  103°  ¥.,  the  pulse  is  increased  in 
rate  and  tends,  in  some  cases,  to  be  small  and  thready.  I^lie 
])atient  coniplains  of  severe  thirst,  and  tlie  tongue  is  coated 
with  a  white  fur.  In  the  very  acute  cases  tJie  patient  becomes 
gravely  ill  within  a  couple  of  days,  abdominal  pain  ijicreases, 
the  mucous  blood-stained  stools  are  very  frequent,  the 
patient  becomes  delirious,  and  may  die  on  tlie  third  or  fourth 
day  of  illness.  In  cases  of  less  severity  the  symptoms  abate 
after  tlie  first  three  or  four  days'  illness;  pain  lessens,  the 
stools  become  less  frequent,  the  temperature  falls  and  con- 
valescence is  established  in  two  or  three  weeks.  In  certain 
cases,  however,  the  disease  takes  on  a  much  more  chronic  form 
after  the  first  acute  symptoms  subside,  and  the  patient  may 
suffer  for  many  weeks  or  even  months  from  three  or  four 
dysenteric  stools  in  the  day,  with  loss  of  apj)etite  and  pro- 
gressiA^e  wasting.  In  bacillary  dysentery  there  is  little  ten- 
dency to  relapse  once  recovery  has  taken  place,  and  abscess 
of  the  liver  is  extremely  rare.  In  a  certain  proportion  of 
cases  a  true  dysentery  may  be  preceded  by  some  days  of  in- 
testinal catarrh,  during  which  the  stools  are  copious,  bile- 
stained  and  watery,  but  as  the  attack  proceeds  the  stools 
become  less  copious  and  more  frequent,  the  movement  of  the 
bowels  is  associated  with  tenesmus,  and  at  last  the  stools  are 
seen  to  be  typically  dysenteric,  and  the  tenesmus  and  abdomi- 
nal pain  are  extreme.  Such  cases  progress  much  as  those 
already  described,  save  that  in  this  tj'pe  fever  is  often  very 
slight,  and  may  be  absent  by  the  time  the  patient  comes  under 
observation. 

CompJications.. — Peritonitis  may  occur,  either  as  the  result 
of  a  spread  of  the  infection  through  the  intestinal  wall  with- 
out rupture,  or  as  a  result  of  perforation.  In  the  former 
kind,  a  perityphlitis  or  periproctitis  may  occur.  The  condi- 
tion is  not  at  all  common. 

Peripheral  neuritis  may  complicate  convalescence.  The 
lower  limbs  are  most  usually  attacked. 

Pleurisy,      venous      thro7nbosis,      and     various      pyajviic 


196  Chapter  XI II. 

manifestations  may  occur  in  severe  cases,  while  endocarditis 
and  pericarditis  are  also  met  with  occasionally, 

A  form  of  arthritis  similar  to  that  which  may  occur  in 
many  acut-e  fevers,  not  definitely  rheumatic,  but  probably  of 
toxic  origin,  has  been  observed  in  some  epidemics. 

Sequelce. — The  most  common  sequelae  of  bacillary  dysen- 
tery are  anoeinia,  a  persistent  dyspepsia,  and  irritability  of  the 
bowel  with  a  tendency  to  frequently-recurring  diarrhoea. 
The  anaemia  may  be  associated  with  oedema  of  the  feet  and 
legs.     A  chronic  nephritis  is  occasionally  met  with. 

Diagnosis. — An  attempt  should  always  be  made  to  isolate 
the  infecting  organism  from  the  stools.  The  B.  dysenterise 
is  a  short  bacillus  with  rounded  ends,  resembling  the  B. 
typhosus  in  appearance,  but  being  less  motile  than  that 
organism,  and  giving  a  more  uniform  indol-production.  When 
grown  in  milk  it  generates  acid  at  first,  but  afterwards  pro- 
duces a  gradually  increasing  alkalinity.  It  does  not  react  to 
the  serum  of  patients  suffering  from  enteric  fever.  Aggluti- 
nation tests  should  always  be  made.  The  serum  of  patients 
suffering  from  bacillary  dysentery  will  agglutinate  cultures  of 
the  B.  dysenterise  in  dilutions  of  1-500  up  to  1-1000. 

The  chief  clinical  distinctions  between  bacillary  and 
amoebic  dysentery  are  that  in  the  former  the  onset  is  usually 
more  acute,  and  relapse  is  not  nearly  so  frequent  as  in  the 
latter,  while  hepatitis  and  hepatic  abscess  are  rare 
complications. 

In  making  a  diagnosis  of  bacillary  dysentery  it  is  neces- 
sary to  exclude  diseases  in  which  dysenteric  symptoms  are  a 
late  manifestation,  such  as  malaria  and  Kala-Azar,  and  to 
exclude  also  diseases  due  to  the  invasion  of  the  bowel  by  the 
Bilharzia  haematobium  or  the  Schistosomum  Mansoni  or 
Japouicum.  Examination  of  the  blood  and  spleen  will  serve 
to  exclude  malaria  and  Kala  Azar,  while  the  ova  of  the  three 
Schistosoma  are  easily  recognised  in  the  stools,  the  S. 
haematobium  having  a  terminal  spine,  the  S.  Mansoni  a 
lateral  spine,  and  the  S.  Japonicum  having  no  spine  at  all. 

Treatment. — It  is  found  that  in  bacillary  dysentery  the 
patient  does  not  respond  to  treatment  by  ipecacuanha  as  do 
those  who  suffer  from  the  amoebic  infection,  and,  on  the  whole. 


Dysentery.  197 

the  best  results  seem  to  have  been  obtained  l)y  tlx;  use  of  tJie 
aperient  sulphates,  sulphate  of  magnesia  or  sulphate  of  soda, 
in  doses  of  thirty  grains,  either  alone  or  in  eombination  witli. 
a  few  minims  of  dilute  sulphuric  acid  and  tincture  of  ginger. 
The  doses  should  be  given  every  hour  until  fairly  free  but 
gentle  purgation  results.  The  doses  may  then  be  given  at 
longer  intervals,  but  a  gentle  purgative  action  should  be  kept 
up  until  some  days  after  the  stools  are  free  from  mucus  and 
blood.  If  the  stools  become  watery  under  this  treatment,  it 
should  be  intermitted. 

Calomel,  in  doses  of  1-^  gr.  every  hour,  may  be  given 
until  the  stools  become  fairly  copious  and  definitely  feculent, 
and,  if  tenesmus  be  severe,  it  may  be  combined  with  small 
doses  of  Dover's  powder. 

Bismuth  is  of  service,  combined  with  opium,  in  those 
cases  where,  although  the  stools  become  feculent  and  blood 
and  mucus  disappear,  more  or  less  diarrhoea  persists.  The 
salicylate  is  the  best  salt  to  use,  and  should  be  given  in  doses 
of  10-20  grains,  every  three  or  four  hours.  Absolute  rest 
including  the  use  of  the  bed-pan,  and  warmth,  are  two  essen- 
tials in  the  treatment  of  the  acute  stages  of  dysentery. 

If  the  dysentery  becomes  chronic,  a  small  dose  of  castor 
oil  should  be  given  thrice  in  the  day  for  about  a  week,  and 
following  this  a  large  enema  of  water  made  alkaline  by  some 
salt  of  soda  should  be  given,  retained  for  some  minutes,  and 
then  allowed  to  escape  thoroughly,  after  which  nitrate  of 
silver  injections  may  be  used.  The  solution  for  injection 
should  consist  of  two  or  three  pints  of  distilled  water  con- 
taining half  a  grain  of  nitrate  of  silver  to  the  pint.  The  in- 
jection should  be  made  by  means  of  a  long,  soft,  indiarubber 
tube,  passed  as  high  as  possible  without  forcing  and  without 
kinking.  The  solution  must  be  allowed  to  run  in  by  gravity, 
and  not  forced  in  by  a  syringe,  and  the  patient  should  retain 
the  injection  as  long  as  possible,  lying  on  the  abdomen.  The 
injections  may  be  repeated  every  two  or  three  days  for  a 
fortnight  or  three  weeks  if  they  appear  to  have  a  good  effect, 
but  if  they  should  produce  any  marked  irritation  or  any 
aggravation  of  symptoms  they  should  at  once  be  discontinued. 


198  Chapter  XIU 

The  Plombieres  douche,  or  a  course  of  the  waters  of 
Vichy,  Kissiugen  or  Carlsbad  may  also  be  employed  in  the 
treatment  of  chronic  bacillary  dysentery. 

Diet. — During  the  acute  stage  the  diet  must  be  fluid  and 
bland,  consisting  of  milk  diluted  with  barley-water  or  rice- 
water  and  whey.  This  fluid  dietary  should  be  maintained 
for  a  few  days  after  all  acute  symptoms  have  subsided,  and  at 
the  end  of  that  time  a  mixed  diet  should  be  resumed  with  the 
utmost  caution,  much  more  careful  graduation  being  needed 
than  in  enteric  fever,  or  even  cholera.  Alcohol  should  be 
forbidden  for  some  time  after  recovery  is  apparently  complete. 
AVhen  the  disease  has  become  chronic,  the  meals  should  be 
small  and  should  consist  of  light  easily-digested  food. 

It  is  the  practice  to  recommend  a  diet  which  excludes 
beef,  mutton,  cheese,  bread,  and  coarse  vegetables,  but  a 
large  number  of  cases  will  be  found  to  do  better,  in  the 
chronic  stage,  if  their  dietary  includes  a  lightly-done  chop  or 
piece  of  fillet-steak;  and  bread,  if  eaten  rather  stale  and 
chewed  almost  to  a  liquid  consistency,  does  not  appear  to  do 
harm. 

Eiyideviiology. — Bacillary  dysenter}?-  occurs  in  epidemic 
form  all  over  the  world,  and  is  common  in  Japan  and  the 
United  States.  It  may  break  out  in  institutions,  particu- 
larly in  asylums.  The  catarrhal,  croupous  and  diphtheritic 
dysenteries  are  probably  all  bacterial  in  origin. 

Method  of  Infection. —  The  causal  agent  of  dysentery  is 
contained  in  the  stools,  and  the  alvine  evacuations  must 
therefore  be  regarded  as  infective.  It  is  possible  that  the  B. 
dysenterise  can  be  spread  by  the  water  supply,  but  it  is  more 
probable  that  it  is  spread  by  infected  dust  in  unclean  districts 
and  carelessly-tended  buildings. 

Period  of  Infectivity. — It  is  well  to  regard  patients  suffer- 
ing from  bacillary  dysentery  as  infectious  until  all  intestinal 
symptoms  have  disappeared,  and  until  examination  of  the 
stools  fails  to  reveal  the  presence  of  the  specific  organism. 

Death-rate. — The  death-rate  varies  very  much  in  different 
epidemics,  and  may  range  from  about  3  per  cent,  to  15  per 


Dysentery.  199 

cent,   in  different  countries  and  at  different  times.        It  has 
been  put  down  in  Japan  as  about  7  per  cent,  on  an  average. 

Home  Frophylaxis.  —  All  cases  of  bacillary 
dysentery  should  be  isolated  with  great  strictness,  whether 
they  occur  in  institutions  or  at  home.  If  there  is  reasonable 
accommodation  in  the  patient's  own  house  there  is  no  need  to 
send  him  to  hospital,  but  he  must  have  a  room  devoted 
entirely  to  his  use.  The  attendants  should  take  the  same 
precautions  as  in  dealing  with  enteric  fever  as  regards  their 
personal  cleanliness  and  the  disinfection  of  the  stools  and 
clothing  with  carbolic  acid,  "  Co-f ectant "  or  formalin.  The 
room  and  house  generally  must  be  disinfected  at  the  end  of 
the  illness. 

Public  Health  AdministTation . — Care  should  be  taken  by 
the  authorities  to  see  that  all  patients  who  are  suffering  from 
bacillary  dysentery  are  properly  isolated  and  that,  when  the 
disease  appears  in  an  institution,  proper  means  are  taken  to 
recognise  the  condition  and  to  deal  with  it  when  it  arises. 
Households  in  which  it  appears  should  be  encouraged  to  dis- 
infect properly,  and  should  be  aided  by  the  Local  Authority 
when  their  means  are  such  as  to  make  proper  disinfection  diffi- 
cult. It  may  be  necessary  to  isolate  cases  of  bacillary  dysen- 
tery in  hospital  when  an  outbreak  occurs  in  an  over-crowded 
and  poverty-stricken  district,  and  also  to  undertake  cleansing 
and  disinfection  of  the  district  on  a  somewhat  extensive  scale. 

Amoebic  Dysentery. —  Clinical  Types.  — -  The  onset  of 
amoebic  dysentery  may  be  sudden  and  acute,  with 
some  fever,  acute  abdominal  pain  and  the  passage  of 
frequent  mucous  stools  tinged  with  blood  accompanied 
by  much  straining,  without  there  having  been  any  pre- 
monitory symptoms  beyond  a  few  hours'  malaise.  In 
such  acute  cases,  sloughs,  sometimes  of  considerable  size,  are 
often  passed.  Occasionally,  after  the  separation  of  the 
sloughs,  extensive  ulceration  of  the  colon  remains,  and  the 
patient  suffers  from  severe  diarrhoea,  emaciates  rapidly,  and 
may  die  in  a  few  months.  Sometimes  the  attack  is  so  acute 
and  severe  that  the  patient  dies  from   asthenia  and  cardiac 

p     2 


200  Chapter  XIII. 

failure  alter  a  Aveek's  illness.  The  majority  of  acute 
cases  of  amoebic  dysentery,  however,  clear  up  in  a  few  weeks, 
and  complete  recovery  takes  place.  In  a  certain  proportion, 
however,  the  disease  gradually  assumes  a  chronic  form,  and  is 
liable  to  frequent  relapses.  In  acute  amoebic  dysentery  the 
abdomen  is  usually  tender,  and  there  is  often  an  enlargement 
of  the  liver,  with  tenderness  in  the  hepatic  region. 

The  commonest  mode  of  onset  of  amoebic  dysentery,  how- 
ever, is  not  acute,  as  described  above,  but  is  insidious, 
and  a  sub-acute  form  of  the  disease  develops,  showing  little 
fever  and  comparatively  slight  abdominal  pain,  with 
the  passage  of  a  moderate  number  of  blood-stained  mucous 
stools  and  considerable  tenesmus.  Such  sub-acute  cases  may 
clear  up  completely  after  a  few  weeks'  illness,  but  in  a  great 
number  of  them  the  disease  becomes  chronic  and  the  patients 
have  periods  of  comparative,  sometimes  almost  complete, 
quiescence  alternating  with  exacerbations,  during  which 
abdominal  pain,  frequent  mucous  blood-stained  stools  and 
much  tenesmus  may  again  appear,  while  there  may  also  be 
some  fever.  This  condition  of  alternating  relapse  and  quies- 
cence may  persist  for  many  months,  and  even  for  some  years. 
In  many  cases  the  patient  suffers  alternately  from  obstinate 
constipation  and  severe  diarrhoea.  In  a  considerable  propor- 
tion of  such  cases  the  patient  feels  comparatively  well,  at 
least  in  the  earlier  stages,  and  maintains  nutrition  to  a  sur- 
prising degree,  but  unless  the  disease  is  checked,  the  chronic 
ulceration  of  the  colon  may  extend  to  all  parts  of  the  intes- 
tinal tract  and  a  destruction  of  the  digestive  glands  occurs 
which  makes  nutrition  impossible,  and  the  patient  gradually 
wastes  and  dies  of  asthenia.  Such  patients  have  a  small  and 
capricious  appetite.  They  suffer  much  from  chronic  dyspep- 
sia, and  sometimes  pass  their  food  by  the  rectum  quite  un- 
altered. They  are  troubled  with  flatulence  and  frequent 
attacks  of  diarrhoea,  and  the  tongue  is  red  and  glazed,  or 
ulcerated  and  tender. 

A  latent  form,  of  amoebic  dysentery  must  be  mentioned,  in 
which  there  are  no  definite  dysenteric  symptoms,  but  in  which 
the  patient  may  suffer  from  repeated  attacks  of  watery 
diarrhoea    or    slight    attacks    of    diarrhoea    alternating    with 


Dysentery.  201 

constipation.  Again,  the  first  indication  of  illness  imay  be  the 
occurrence  of  hepatitis  with  or  without  abscess,  and  Leonard 
Rogers  has  found  'post  mortem  distinct  evidence  of  dysenteric 
ulceration  in  the  caecum  and  ascending  colon  in  patients  who 
had  not  suffered  from  any  intestinal  symptoms.  This  type  is 
of  interest  in  connection  with  the  occurrence  and  treatment 
of  hepatitis  and  hepatic  abscess. 

C amplications . — Of  all  the  complications  of  ania;l)ic  dysen- 
tery hepatitis  and  liepatic  abscess  are  the  commonest.  A 
large  and  tender  liver  is  quite  a  usual  accompaniment  of  an 
acute  amoebic  dysentery,  but  the  hepatitis  may  subside  with 
the  dysenteric  attack,  and  may  not  again  declare  itself.  On 
the  other  hand,  it  may  appear  at  varying  periods  after  the 
attack  of  dysentery  has  apparently  subsided,  and  is  of  common 
occurrence  during  the  course  of  a  chronic  attack  of  amoebic 
dysentery.  Hepatitis  is  indicated  by  some  enlargement  of  the 
liver  with  pain  and  tenderness  in  the  epigastrium  and  in  the 
hepatic  region  generally.  There  is  in  most  cases  some 
irregular  intermittent  or  remittent  pyrexia.  When  hepatitis 
is  suspected,  a  blood-count  should  be  made,  and  the  presence 
of  a  leukocytosis,  varying  as  a  rule  between  12,000  and 
20,000  per  cubic  millimetre,  is  at  least  strongly  suggestive  of 
the  existence  of  hepatic  inflammation.  Hepatitis,  if  allowed 
to  progress  untreated,  not  infrequently  proceeds  to  the  forma- 
tion of  an  hepatic  abscess.  The  patient  emaciates,  suffers 
from  chill  and  cold  sweats,  particularly  at  night,  and  may  be 
troubled  with  a  short  dry  cough,  or  rheumatic  pains  with 
swelling  of  the  feet  and  hands  may  be  present.  Pain  in  some 
part  of  the  hepatic  region  is  very  common,  and  a 
limited  area  of  tenderness  on  pressure  may  be  a  valuable 
aid  in  the  localising  of  the  abscess.  In  a  certain  proportion 
of  cases  pain  in  the  right  shoulder  or  in  the  region  of  the 
right  scapula  may  be  present,  and  the  pain  sometimes  tends 
to  travel  down  the  right  arm.  The  liver  dullness  may  be  in- 
creased upwards  or  downwards,  or  in  both  directions.  Occa- 
sionally its  extension  is  limited  and  indicates  the  position  of 
the  abscess.  If  there  is  no  operative  interference,  the  patient 
may  die  of  toxaemia  without  rupture  of  the  abscess,  or  the 
abscess  may  burst  into  the  lung  or  pleura  or  into  the  stomach, 


202  Chaptei'  XII I. 

intestiue,  peritoneum,  lumbo-iliac  region  or  pericardium.     In 
some  cases  rupture  is  followed  by  spontaneous  cure. 

Hcemorrhage  froin  the  intestine  is  another  complication 
wliich  may  be  dangerous,  but  it  occurs  in  only  a  small  pro- 
portion of  cases. 

Perforation  of  the  intestine  tlirougli  a  dysenteric  ulcer 
has  occasionally  been  seen. 

Gangrene  of  the  mucous  membrane  of  the  colon  some- 
times occurs  in  severe  ulcerative  cases,  and  when  it  does  occur 
the  stools  consist  of  dirty  fluid  like  ''flesh  washings."  A 
"  coffee-ground  "  material  deposits  after  they  are  allowed  to 
stand  for  a  time,  and  they  have  a  most  offensive  smell.  Some- 
times large  sloughs  of  mucous  membrane  are  recognisable  in 
the  stools,  occasionally  of  a  tubular  form.  The  patient  sweats 
profusely  and  becomes  rapidly  weak,  he  develops  a  low  mut- 
tering delirium,  the  heart  fails  and  death  is  the  almost 
invariable  termination  of  the  case. 

SequelcE. — Intestinal  obstruction  from  cicatrisation  of  the 
gut  has  been  known  to  occur  as  a  sequel  of  chronic  amoebic 
dysentery,  but  the  most  troublesome  sequela  is  the  chronic 
dyspepsia,  the  tendency  to  diarrho2a,  and  the  malnutrition 
which  so  frequently  follow  a  chronic  attack.  It  is  possible 
that  the  atrophy  of  the  secreting  structures  of  the  whole 
gastro-intestinal  tract  with  ulceration  and  tenderness  of  the 
tongue  may  be  the  result  of  an  attack  of  "  Sprue  "  taking 
effect  on  an  already  weakened  intestine.  Patients  who  develop 
this  "  sprue  "-like  condition  iuA^ariably  die  sooner  or  later 
from  the  effects  of  malnutrition. 

Diagnosis. — The  diagnosis  of  amoebic  dysentery  depends  on 
the  discoA^ery  of  the  amoeba  dysenteria;  in  the  stools.  If 
some  of  the  faeces  of  a  person  suffering  from  dysentery  be 
spread  on  a  slide  and  examined  microscopically  on  a  warm 
stage,  the  anioebse  are  seen  as  small  greenish  translucent  bodies 
about  four  times  the  size  of  a  red  blood-corpuscle.  They  have 
a  clear  outer  rim — the  ectosarc,  and  a  finely-granular  inter- 
nal mass — endosarc,  and  show,  as  a  rule,  one  or  two  con- 
tractile vacuoles.  They  usually  contain  the  remains  of  red 
blood-corpuscles,  crysials  of  various  kinds,  and  bacteria.     On 


Dysentery.  203 

the  warm  stage  they  exhibit  the  crawling  movement  with  ])ro- 
trusion  of  pseudopodia,  wliich  is  tlie  characteristic  of  amciibai  iu 
general.  When  dried,  the  amceba  of  dysentery  takes  on  a 
very  resistant  form,  and  in  this  state  is  capable  of  resisting 
the  gastric  juices. 

Especially  in  acute  cases,  the  diagnosis  is  usually  easy, 
but  it  must  be  remembered  that  the  presence  of  the  Schis- 
tosomum  hsematobium,  the  S.  Japonicum,  and  the  S. 
Mansoni,  malaria,  Kala  Azar,  haemorrhoids,  tumour  of  the 
colon  or  sigmoid  flexure,  may  all  give  rise  to  dysenteric  symp- 
toms, and  care  must  be  taken  to  exclude  them  in  arriving  at 
a  diagnosis. 

TreatTTient. — Absolute  rest  and  careful  dieting,  are  neces- 
sary in  all  cases  of  amoebic  dysentery,  even  in  those  which 
appear  to  be  chronic.  Among  drugs,  iijecacuanha  holds  the 
foremost  place,  both  in  the  treatment  of  the  dysentery  itself 
and  the  concomitant  hepatitis.  It  should  be  given  in  large 
doses — 20-30  grains  twice  in  the  day  being  necessary  to  pro- 
duce the  desired  effect.  It  is  best  given  in  the  form  of 
freshly-made  pills,  or  in  gelatine  capsules,  or  as  a  bolus  in 
rice-paper.  On  account  of  its  emetic  action  certain  pre- 
cautions must  be  taken  in  its  administration.  It  must  be 
given  on  an  empty  stomach,  and  it  is  well  to  withhold  all 
food  for  three  hours  before  giving  the  ipecacuanha.  Thirty 
minims  of  chlorodyne  or  twenty  minims  of  laudanum  should 
then  be  given  in  an  ounce  of  water  and  a  mustard  poultice 
applied  to  the  epigastrium.  About  twenty  minutes  later  the 
patient  should  take  the  ipecacuanha  and  lie  flat  on  the  back 
without  moving  or  speaking  for  some  hours.  He  must  not 
swallow  his  saliva,  but  should  indicate  to  his  attendant  when 
he  wishes  to  get  rid  of  it  and,  with  as  little  movement  as 
possible,  spit  it  into  a  towel  held  for  him  for  the  purpose. 
Nausea  must  be  strenuously  resisted.  Five  to  eight  hours 
after  taking  the  ipecacuanha,  and  after  nausea  has  dis- 
appeared, the  patient  may  begin  to  take  small  quantities  of 
food  of  a  fluid  or  semi-fluid  character,  and  feeding  with  small 
quantities  should  be  continued  for  some  five  hours,  at  the  end 
of  which  everything  should  be  withheld  from  the  stomach 
for  an  hour  or   so   and   ipecacuanha   given   again,    the   same 


204  Chapter  XIII. 

precautious  being  observed  as  after  the  first  dose.  It  is  not  so 
necessary  as  before  the  first  dose  to  withhold  food  for  some 
hours  before  its  administration  for  the  second  time,  but  the 
precautions  to  avoid  nausea  should  be  as  strict.  Ipecacuanha 
ought  to  be  repeated  once  or  twice  a  day  for  at  least  a  week 
after  the  stools  have  become  copious,  feculent  and  yellow. 
Diarrhoea  is  no  indication  for  stopping  treatment  by  ipeca- 
cuanha. Some  three  or  four  days  after  the  improvement  in 
the  character  of  the  stools  has  been  observed,  it  is  best  to 
reduce  the  dose  by  5  grains  daily. 

Not  only  is  ipecacuanha  useful  in  the  acute  stage  of  the 
disease,  but  if  the  disease  becomes  chronic  the  large  doses 
should  be  resumed  and  given  a  fair  trial  before  being  replaced 
by  other  forms  of  treatment.  When  hepatitis  exists  after  a 
patient  has  had  dysentery,  or  even  when  hepatitis  is  present 
when  the  patient  has  had  no  definite  symptoms  of  dysentery, 
it  is  advisable,  at  least  in  tropical  and  sub-tropical  countries, 
to  treat  the  condition  by  ipecacuanha  in  large  doses  for  some 
time  after  all  symptoms  have  disappeared.  The  results  of 
Leonard  Rogers  are  very  striking,  and  encourage  one  to 
recommend,  as  he  does,  that  even  when  a  patient  suffers  from 
an  obscure  pyrexia  and  shows  a  leukocytosis  while  he  is  living 
or  when  he  has  lived  in  a  district  where  dysentery  is  common, 
a  course  of  treatment  by  ipecacuanha  should  be  insti- 
tuted when  careful  examination  of  the  blood  and  spleen  has 
excluded  the  possibility  of  the  disease  being  malaria  or 
Kala  Azar.  It  is  probable  that,  if  ipecacuanha  in  sufficient 
dosage  were  more  generally  used  in  the  treatment  of  amoebic 
dysentery  and  in  the  treatment  of  hepatitis  of  obscure  origin, 
hepatic  abscess  would  be  of  much  rarer  occurrence  than  at 
present. 

When  an  hepatic  abscess  has  formed,  the  treatment  is 
purely  surgical.  Exploratory  punctures  should  be  made  in 
all  cases  where  there  is  any  doubt  as  to  its  localisation,  and 
search  should  not  be  stopped  until  five  or  six  punctures  have 
been  made.  But  it  is  Avell  to  add  that  exploratory  punctures 
should  never  be  made,  unless  the  abscess  is  very  apparent, 
until  after  some  days'   treatment  with  ipecacuanha.        After 


Dysentery,  205 

the  abscess  lias  been  localised  it  should  be  punctured,  and 
thorough  drainage  established,  after  the  method  described  in 
detail  by  Manson. 

Where  persistent  vomiting  makes  treatment  by  ipeca- 
cuanha impossible,  one  is  compelled  to  fall  back  on  the  use  of 
the  aperient  sulphates  and  calomel,  as  described  under  the 
heading  of  "Treatment"  in  the  section  on  bacillary 
dysentery. 

In  chronic  amoebic  dysentery,  if  the  patient  has  been 
previously  treated  by  inadequate  doses  of  ipecacuanha,  or  if 
some  time  has  elapsed  sincie  the  ipecacuanha  treatment  was 
stopped,  this  drug  should  be  given  in  doses  of  30,  25,  20,  15, 
10,  and  5  grains  on  six  successive  nights,  and  the  patient 
should  thereafter  be  put  on  small  doses  of  castor  oil  thrice 
daily,  the  diet  being  carefully  limited  to  milk  and  barley- 
water.  After  this  he  should  bo  given  some  weeks'  treatment 
with  salol  or  small  doses  of  calomel,  and,  in  addition,  enemata 
of  salt  and  water  may  be  given  with  adA^antage. 

If  these  means  fail,  the  large  injection  of  a  weak  solution 
of  nitrate  of  silver  as  described  in  the  section  on  "  Bacillary 
Dysentery"  should  be  tried,  or  similar  large  injections  con- 
taining quinine  in  solution  of  a  strength  of  1-5000  to  1-2500 
instead  of  the  nitrate  of  silver  may  be  used,  and  retained  for 
15  minutes.  Milk  and  weak  solutions  of  sulphate  of  copper 
or  tannin  are  also  recommended.  Straining  and  abdominal 
pain  may  be  relieved  by  small  starch  and  opium  enemata. 

The  constipation  which  is  not  uncommonly  a  troublesome 
sequel  of  dysentery  should  be  treated  first  by  repeated  enemata 
of  water  made  slightly  alkaline,  or  by  injections  of  linseed  in- 
fusion or  barley-water.  A  teaspoonful  of  castor  oil  twice  or 
thrice  a  day  is  a  useful  method  of  treatment,  and  may  be  sup- 
plemented by  an  occasional  soap  or  glycerine  suppository.  A 
course  of  Carlsbad  or  Marienbad  waters  is  also  effective  in 
many  cases.  The  greatest  care  to  avoid  chill  should  be  taken 
by  those  who  have  recently  had  dysentery  or  who  suffer  from 
chronic  dysentery.  Cold  baths  should  not  be  taken,  and 
cold  and  damp  climates  must  be  regarded  as  dangerous. 

Diet. — The  same  principles  of  diet  apply  to  amoebic  as  to 
bacillary   dysentery,    and   alcohol   should  be   equally   avoided 


206  Chapter  XIII. 

during  au  attack  and  for  some  time  after  its  termination, 
wlietlier  it  be  acute  or  chronic. 

Epidemiology. — Amoebic  dysentery  is  endemic  in  many 
parts  of  the  world.  It  is  found  in  the  southern  parts  of  the 
United  States  of  America,  in  the  West  Indies,  in  Egypt, 
Arabia,  Africa,  China,  India  and  the  warmer  parts  of  the 
globe  generally.  It  is  not  found,  save  in  the  form  of  occa- 
sional imported  cases,  in  the  more  temperate  latitudes.  It 
occurs  in  warm  countries  also  in  a  sporadic  form. 

Amoebic  dysentery  not  infrequently  coexists  with  a  bacil- 
lary  dysentery. 

Method  of  Infection. — Amoebic  dysentery  is  usually  a  water- 
borne  disease,  and  contaminated  wells  and  polluted  rivers  are 
the  commonest  means  of  its  conveyance,  but  it  may  also  be 
spread  by  dust  contaminated  by  the  evacuations  of  those 
suffering  from  the  disease. 

Period  of  Infectivity. — It  is  right  to  regard  a  patient  as 
infectious  until  at  least  seven  days  after  the  amoeba  has 
apparently  disappeared  from  the  stools. 

Death-rate. — As  in  bacillary  dysentery,  this  is  very  diffi- 
cult to  gauge  accurately,  and,  from  the  study  of  statistics  from 
various  parts  of  the  world,  .seems  to  vary  from  2-40  per  cent 
in  different  outbreaks  according  to  the  place  and  race  of  those 
attacked.  In  the  East,  the  natives  show  a  higher  mortality 
than  Europeans,  probably  largely  on  account  of  their  different 
hygienic  surroundings  and  less  careful  feeding. 

Home  Prophylaxis . — All  patients  who  are  suffering  from 
amoebic  dysentery  should  be  isolated.  Extreme  care  must  be 
taken  by  those  who  are  still  healthy  to  avoid  contamination 
by  the  dried  stools  of  those  suffering  from  the  disease,  either 
through  the  medium  of  clothing  or  of  vessels.  The  amoeba  in 
its  moist  "vegetable"  stage  does  not  seem  nearly  so  capable 
of  producing  an  attack  of  dysentery  as  when  it  has  assumed 
its  dry  and  extremely  resistant  form.  Great  care  rnaust  be 
taken,  therefore,  to  keep  the  patient  and  his  bedclothes  clean, 
and  the  stools  ought  to  be  immediately  disinfected  by 
formalin,  "  Co-fectant,"  or  some  crude  preparation  of  phenol. 
The   attendants   must   exercise   the   most   scrupulous   care    as 


Dysentery.  207 

regards  personal  cleanliness,  and  pay  particular  attention  to 
the  hands  and  nails,  bathing  them  with  a  solution  of  per- 
manganate of  potash  after  washing.  At  the  termination  of 
the  case  the  sick-room  and  everything  which  has  been  in  con- 
tact with  the  patient  should  be  tliorouglily   disinfected. 

In  every  district  where  dysentery  is  endemic  the  greatest 
care  should  be  taken  to  insure  the  purity  of  the  water  supply, 
and  all  water  should  be  boiled  before  drinking.  The  house 
must  be  well-kept,  and  not  permitted  to  harbour  dust  or  dirt. 
The  greatest  care  must  be  taken  to  keep  the  bowels  regular, 
to  avoid  chill,  unwholesome  food,  and  intemperance  in  eating 
or  drinking;  in  other  words  to  avoid  everything  which  will 
tend  to  encourage  catarrh  of  the  gastro-intestinal  tract. 

Public  Health  Administration. — This  resolves  itself  into 
seeing  that  the  water-supply  is  pure,  that  the  disposal  of 
sew^age  is  safely  and  efficiently  done,  and  that  household 
cleanliness  is  as  perfect  as  possible.  All  collections  of  rub- 
bish must  be  disinfected  and  removed  and  all  receptacles  for 
rubbish  frequently  lime-washed. 

The  disinfection  of  houses  where  dysentery  has  occurred 
and  of  all  articles  which  have  been  in  contact  with  a  patient 
Bhould  be  undertaken,  while  those  who  are  suffering  from  the 
disease  must  be  strictly  isolated,  either  at  home,  if  their 
accommodation  is  sufficient,  or  in  hospital  if  it  is  not. 


(  208  ) 


Chapter   XIV. 

KALA    AZAR 

Synonyms.  —  Dum-dum  Fever,  Burdwan  Fever,  Black 
Sickness,  Sirkari  disease.  Sahib's  disease,  Tropical 
Splenomegaly. 

Definition.  —  A  specific  infective  disease,  characterised  by 
a  chronic  course,  irregular  pyrexia,  enlargement  of  the  spleen 
and  liver,  progressive  wasting  and  anaemia,  with,  in  many 
cases,  an  unusual  deposition  of  pigment  in  certain  parts  of  the 
skin.  The  disease  is  presumably  caused  by  a  protozoal  or- 
ganism belonging  to  the  genus  Her'petomenas  which  is  present 
in  the  blood,  particularly  in  the  spleen  and  liver,  in  the  form 
of  the  "  Leishman-Donovan  bodies,"  discovered  by  Leishman 
fost  Tnortem  in  1900,  and  in  the  splenic  blood  during  life  by 
Donovan  in  1903. 

Incubation  Period. — The  incubation  period  of  Kala  Azar  is 
difficult  to  determine.  Manson  quotes  the  case  of  an  English- 
man who  was  previously  in  perfect  health,  but  who  fell  ill  of 
Kala  Azar  within  ten  days  of  his  coming  to  a  district  where 
the  disease  was  endemic.  It  is  probable,  however,  that  the 
usual  incubation  period  is  considerably  longer. 

Rash. — No  eruption  has  been  described  as  typical  of  the 
disease. 

Clinical  Types. —  Kala  Azar  may  have  an  acute  or  an 
insidious  onset. 

In  cases  with  an  acute  onset,  the  disease  may  be  ushered 
in  by  rigors,  repeated  daily  perhaps  for  several  days,  and 
often  recurring  at  intervals  throughout  the  attack.  The  fever 
is  usually  of  a  high  continued  or  high  remittent  type  at  the 


KaJa  Azar.  209 

commencement  of  the  attack,  but  tends  to  show  greater  remis- 
sions as  tlie  attack  proceeds,  and  may  be  quite  definitely  inter- 
mittent in  character.  In  such  cases,  the  fever  continues  for 
some  two  to  six  weeks,  when  a  period  of  complete  or  almost 
complete  apyrexia  begins.  This  period  of  apyrexia  lasts  for  a 
very  variable  time,  from  a  few  days  to  some  weeks,  and  is  fol- 
lowed by  another  febrile  movement,  not  usually  so  severe  as 
the  first.  The  alternation  of  fever  with  periods  of  normal 
temperature  may  persist  for  some  months,  but  sooner  or  later 
the  fever  assumes  a  continuous  low  remittent  or  intermittent 
type,  and  the  patient  presents  the  emaciated  appearance  so 
usual  in  the  later  stages  of  the  disease. 

Rogers  points  out  that  the  remittent  type  of  fever,  especi- 
ally if  it  be  fairly  high,  shows  a  rise  of  temperature  twice  in 
the  twenty-four  hours  with  wonderful  regularity  in  a  striking 
number  of  cases.  This  "  double  remittent"  type  of  fever  he 
considers  so  peculiar  to  Kala  Azar  as  to  be  in  itself  strongly 
suggestive  of  the  presence  of  the  disease. 

From  the  onset  of  fever  the  spleen  enlarges,  showing,  at 
first,  fluctuation  in  size  more  or  less  comparable  with  the 
variations  in  the  febrile  movement,  but  soon  exhibiting  per- 
manent and  progressive  enlargement. 

The  liver  also  enlarges  in  from  40  to  70  per  cent,  of  cases 
as  the  disease  progresses. 

Headache,  nausea  and  vomiting  are  not  at  all  constant 
even  during  the  period  of  invasion,  but  occur  in  a  relatively 
very  small  number  of  cases  as  compared  with  other  infectious 
fevers. 

In  cases  where  the  onset  of  the  disease  is  insidious,  the 
patient  may  present  himself  as  suffering  from  general  malaise 
and  weakness  of  gradual  onset,  and  is  found  to  have  a  pyrexia 
of  varying  intensity,  perhaps  of  the  lower  remittent  or 
^'double-remittent"  type  or  of  a  low  continued  type,  while 
the  spleen  may  be  enormously  enlarged.  The  splenic  en- 
largement may  be  out  of  all  proportion  to  the  apparent  dura- 
tion of  his  illness,  and  is  suggestive  of  a  prolonged  infection, 
during  the  earlier  stages  of  which  fever  and  other  constitu- 
tional disturbances  may  have  been  so  slight  as  to  escape 
attention. 


210  Chapter  XIV. 

lu  all  cases,  whether  the  onset  has  been  acute  or  not,  the 
course  of  the  disease  is  chronic,  and  the  patient  may  drag  out 
an  enfeebled  existence  for  months,  or  even  years,  suffering 
from  a  low  type  of  continued  remittent  or  intermittent  fever 
with  occasional  periods  of  apyrexia,  and  enlargement  of  spleen 
and  liver  with  anaemia  and  emaciation,  until  he  either  recovers 
or,  as  is  much  more  common,  dies  from  some  inter- 
current disease  or  from  sheer  asthenia.  Petechice  may 
appear  on  the  skin,  especially  in  the  region  of  the  axilla,  and 
bleeding  may  occur  from  the  gums,  nose  or  intestine. 

The  appetite  and  digestion  usually  remain  wonderfully 
good  even  in  the  later  phases  of  the  attack. 

Ancemia  becomes  marked  as  the  disease  progresses,  but 
the  reduction  in  the  number  of  red  cells  may  not  be  extreme. 
The  striking  point  about  the  blood  condition  is  the  leukopaenia 
which  is  found,  and  in  this  leukopsenia  the  polymorphs  are 
reduced  in  number  out  of  all  proportion  to  the  mononuclear 
cells,  so  that  a  percentage  estimation  of  the  white  cells  will 
show  a  relative  increase  of  mononuclears  as  compared  with 
polymorphs. 

In  association  with  the  anemia,  hcemic  murmurs  are  fre- 
quently heard  over  the  prsecordium,  and  cedcTna  of  the  feet 
and  legs  is  not  uncommon. 

An  irregularly  distributed  pigmentation  of  the  skin,  like 
large  deeply-coloured  freckles,  is  often  seen  on  various  parts 
of  the  body,  with  a  tendency  to  be  most  marked  in  the  flexures. 
The  skin  generally  becomes  dull  and  earthy-looking,  and  the 
hair  grows  dry  and  brittle. 

At  all  stages  of  the  disease  siveating  is  common  during 
any  remission  of  the  fever. 

Complications. — Diarrhoea  is  not  infrequent  in  the  chronic 
stage  of  Kala  Azar,  and  during  its  occurrence  the  spleen  may 
be  for  a  time  greatly  reduced  in  size.  Dysentery  occurs  in  a 
certain  proportion  of  cases,  more  commonly  in  natives  than  in 
Europeans,  and  very  frequently  proves  fatal.  The  dysentery 
is  usually  of  the  bacillary  type.  Phthisis,  hcemorrhages  of 
various  kinds,  and  pneujnonia  are  met  with  as  terminal  com- 
plications of  the  disease,  but  not  with  the  same  frequency  as 
many    septic    conditions,    of   which   the   most   important    are 


Kaia  Azar.  211 

cancrum  oris,  slouyhiny  of  vuriuus  purls,  uud  irdddle  ear  sup- 
yiiro.tion.  Of  these  cotnplicatioiis,  cancrum  oris  seems  to  be 
the  most  common  and  the  most  fatal,  and  pneumonia  follows 
next  in  frequency  and  danger.  Sloughing  of  the  tissues  of 
the  mouth  is  specially  common  as  a  terminal  event  in  the 
Soudan.  Bronchial  catarrh  is  rare,  especially  in  the  earlier 
stages  of  the  disease,  and  is  found  mostly  as  a  basal  condition 
in  very  asthenic  patients.  Ascites  may  be  met  with  as  the 
result  of  cirrhosis  of  the  liver  following  on  long  standing 
chronic  enlargement. 

Diagnosis. —  It  is  very  difficult  to  distinguish  an  early  case 
of  Kala  Azar  with  high  remittent  or  continued  fever  from 
enteric  fever  and  remittent  malaria.  If  the  pyrexia  is  of  the 
"  double  remittent  "  type  the  disease  is  probably  Kala  Azar, 
and  the  absence  of  any  pulmonary  or  bronchial  catarrh  would 
be  evidence  against  its  being  enteric  fever,  but  Widal's  test 
and  the  examination  of  the  blood  for  the  parasite  of  malaria 
and  the  Leishman-Donovan  bodies  must  be  undertaken  to  con- 
firm the  diagnosis.  In  both  enteric  fever  and  Kala  Azar  a 
leukopesnia  is  the  rule,  but  this  is  much  more  marked  in  the 
latter  disease,  and  the  leukopaenia  of  enteric  fever  does  not 
show  the  marked  diminution  in  the  polymorphs  and  the  rela- 
tive increase  in  mononuclears  which  is  met  with  in  Kala  Azar. 
In  the  early  stages  of  Kala  Azar,  however,  the  leukopaenia 
may  not  be  typical,  so  that  it  may  be  necessary  to  depend  on 
the  examination  of  the  blood  for  a  diagnosis,  and,  when  re- 
peated examinations  of  the  peripheral  blood  has  failed  to 
reveal  the  presence  of  the  Leishman-Donovan  bodies  and 
where  there  is  no  definite  evidence  of  malaria  or  enteric  fever, 
one  may  be  compelled  to  resort  to  puncture  of  the  spleen  or  of 
the  liver,  if  it  be  also  enlarged,  for  the  recovery  of  the  bodies. 
In  the  early  stages  of  the  disease  puncture  of  the  spleen  is  a 
comparatively  safe  operation,  but  even  in  the  early  stages  the 
coagulability  of  the  blood  should  be  estimated,  and  if  the 
coaffulation-time  should  exceed  five  minutes,  as  estimated  bv 
Wright's  coagulometer,  the  operation  should  not  be  under- 
taken, as  death  from  haemorrhage  has  not  infrequently  fol- 
lowed on  splenic  puncture.  This  accident  is  not  so  likely  to 
happen  in  the  early  as  in  the  late  stages  of  the  disease  where 


212  Chapter  XIV. 

the  coagulabilit}'  of  the  blood  is  alwaj^s  low,  and  it  is  fortu- 
nate that  it  is  only  in  the  early  stages  that  the  operation  is 
likely  to  be  necessary,  since  it  is  at  this  time  that  the  Leish- 
man-Donovan  bodies  are  apt  to  be  difficult  of  recovery  from 
the  peripheral  blood.  In  the  later  stages  of  the  disease,  it  is 
usually  possible  to  recover  them  easily  from  the  peripheral 
blood,  or  if  this  is  impossible,  they  may  be  recovered  from 
the  enlarged  liver.  It  must  be  remembered  that  puncture  of 
the  liver  is  a  much  safer  operation  than  puncture  of  the  spleen. 

Just  before  the  liver  or  the  spleen  is  punctured  it  is 
best  to  give  the  patient  a  dose  of  20  to  30  grains  of  calcium 
chloride,  as  recommended  by  Rogers,  in  the  hope  that  it  may 
increase,  even  temporarily,  the  coagulability  of  the  blood. 

Kala  Azar  in  its  later  and  most  typical  stages  is  apt  to  be 
confounded  with  malarial  cachexia ;  but  the  failure  to  find 
the  malarial  parasite,  the  failure  of  the  quinine  test,  and  the 
typical  kind  of  leukopsenia  present,  all  aid  to  the  formation  of 
.a  presumptive  diagnosis  of  Kala  Azar,  while  the  Leishman- 
Donovan  bodies  can  usually  be  discovered  in  the  peripheral 
blood,  and  in  the  liver  after  puncture.  It  is  wise  not  to 
attempt  splenic  puncture  in  the  late  stages  of  the  disease  on 
^account  of  the  fatalities  which  have  attended  the  perform- 
ance of  the  operation,  even  after  precaution  has  been  taken 
to  guard  against  accident.  The  enlargement  of  the  liver  com- 
monly present  in  the  later  stages,  and  the  freckling  of  the 
skin  also  help  to  distinguish  the  disease  from  malaria. 

Short  of  the  discovery  of  one  or  other  of  the  infecting 
organisms,  the  differentiation  between  Kala  Azar  and 
trypanosomiasis  may  be  a  matter  of  great  difficulty,  if  not 
impossibility,  in  those  countries  where  both  diseases  occur  in 
endemic  form. 

The  "  Leishman-Donovan  bodies  "  are  found  in  the  en- 
dothelial cells  of  blood-vessels,  and  are  seen  in  the  large 
mononuclear  cells  in  the  pulp  of  the  spleen,  the  liver,  the 
bone-marrow,  the  kidney,  in  papules  and  ulcers  on  the  skin, 
and  in  petechise.  In  the  peripheral  blood  they  are  found  in 
leukocytes,  both  polymorphonuclear  and  mononuclear.  Stained 
"by  Leishman's  modification  of  the  E-omanowsky  method,  they 
appear  as   small  oval   bodies  about    2  to  4    /u,    in  diameter. 


Kala  Azo7.  213 

Tliey  show  two  lilac-coloured  cliroinaliii  iriiisses  enclosed  in 
protoplasm  wliicli  stains  a  faint  l)lue  coloui-  ;it  tlio  periphery 
of  the  body.  The  larger  and  less  de(q)ly  stained  mass  is  tlie 
nucleus,  and  the  smaller  and  more  deeply  stained  mass,  wliicli 
is  rod-shaped  and  placed  perpendicularly  or  at  a  tangent  to 
the  nucleus,  is  the  micronucleus  or  blepharoplast.  Culti- 
vated outside  tlie  body  in  the  acid  medium  recommended  by 
liogers,  who  first  cultivated  these  organisms,  the  parasites 
rapidly  enlarge,  assume  a  pyriform  shape  and  develop  a 
flagellum.     They  grow  best  at  a  temparature  of  20°-22°  C. 

Treatment. — The  treatment  of  Kala  Azar  has  been  singu- 
larly unsatisfactory.  Arsenic  seems  to  be  of  no  avail,  even 
in  the  form  of  Atoxyl,  and  it  is  not  probable  that  the  prepara- 
tion of  Ehrlich  and  Hata  known  as  "  606  "  or  "  Salvarsan  " 
will  give  better  results.  Manson  has  seen  no  good  results 
from  the  use  of  quinine  and,  indeed,  believes  that  it  may  do 
harm.  Rogers,  on  the  other  hand,  considers  that  quinine 
by  the  mouth  should  be  pushed  in  doses  of  30  to  60  grains  in 
the  day,  more  especially  if  the  case  is  a  comparatively  early 
one,  for  weeks  if  necessary,  and  supports  his  views  by  his 
personal  experience  and  by  the  results  obtained  by  Dodds 
Price  in  Assam.  It  is  a  difficult  matter  to  give  accurate 
figures  regarding  the  results  on  account  of  the  extreme 
chronicity  of  the  disease  and  the  remarkable  spontaneous 
cures  which  sometimes  occur,  but  the  experience  of  Rogers  in 
the  reduction  of  a  high  continued  or  high  remittent  pyrexia 
to  a  slight  low  remittent  pyrexia  after  the  use  of  large  doses 
of  quinine,  would  make  one  rather  believe  that  the  drug  is 
worthy  of  serious  trials  in  suitable  dosage,  especially  when 
the  disease  has  been  diagnosed  in  an  early  stage. 

A  patient  who  has  developed  Kala  Azar  should  be  moved 
as  soon  as  possible  to  a  warm  healthy  climate  and  put  under 
as  good  hygienic  conditions  as  possible. 

Diet. — A  diet  as  generous  and  varied  as  lies  within  the 
patient's  means  and  physical  tolerance  should  be  given  in 
Kala  Azar,  save  when  the  occurrence  of  high  pyrexia,  pneu- 
monia, or  dysentery  requires  its  modification. 

Epidemiology. — Kala  Azar  is  endemic    in    Madras,    Lower 
Bengal,  Assam  and  in  the  United  Provinces    of    Agra    and 

Q 


214  Chapter  XIV. 

Oudh,  aud  lias  slowly  spread  up  the  valley  of  the  Brahma- 
putra iu  Assam  in  epidemics  of  great  severity.  The 
disease  is  clinically  identical  with  an  epidemic  which  raged  in 
Lower  Bengal  between  1854  and  1873,  and  was  called 
Burdwan  Fever.  It  is  probable  that  the  disease  w^as  intro- 
duced into  Assam  from  this  epidemic  in  Bengal.  As  the 
epidemic  spread  in  Assam  it  tended  to  die  down  in  places 
which  it  had  previously  devastated,  and,  as  is  the  case  in 
Lower  Bengal,  sporadic  cases  now  occur  in  these  districts, 
although  the  disease  no  longer  appears  in  epidemic  form 
there.  Sporadic  cases  occur  also  all  over  the  Eastern  side  of 
India,  especially  in  Madras,  Lower  and  Western  Bengal, 
Agra  and  Oudh.  There  seems  to  be  no  difference  in  the  sus- 
ceptibility of  the  sexes  to  Kala  Azar  when  both  are  equally 
exposed  to  infection.  Children  take  the  disease  in  large 
numbers. 

The  native  and  Eurasian  population  who  live  under  the 
worst  hygienic  conditions  are  attacked  with  greater  frequency 
than  Europeans,  and  it  is  interesting  to  note  that  Europeans 
are  attacked,  other  things  being  equal,  almost  in  proportion 
to  the  shortcomings  of  their  hygiene.  Another  fact  of  in- 
terest regarding  the  infection  of  Europeans  is  that  Kala 
Azar  attacks  those  who  have  lived  for  many  years  in  India 
rather  than  newcomers  to  the  country. 

Kala  Azar  tends  to  be  more  common  in  the  "  cold  season" 
in  India,  and  is  always  more  prevalent  after  a  succession  of 
prolonged  "  cold  weathers." 

In  recent  years  Kala  Azar  has  been  discovered  to  be 
epidemic  in  certain  districts  of  the  Soudan,  and  deaths  have 
occurred  from  this  disease  among  both  natives  and  Europeans 
serving  with  the  Egyptian  Army  in  the  more  southern  limits 
of  Soudanese  territory. 

Method  of  Infection. — It  is  probable  that  Kala  Azar,  like 
malaria,  is  not  directly  contagious,  but  that  the  disease  is 
carried  from  person  to  person,  or  from  soil  to  man  by  the 
intermediary  of  some  biting  insect,  and  the  most  likely  insect 
is  the  common  bed-bug  which  is  so  common  in  India  and 
Africa.  Moreover,  the  acidity  of  the  bed-bug's  stomach 
seems  to  favour  particularly  the  development  of  the  flagellated 


Kola  Azar.  216 

stage  of  the  parasite,  and  tljo  way  in  which  the,  disease  tends 
to  cling  to  rooms  and  dwellings  is  also  in  favour  of  iis  hcing 
spread  by  some  insect  which  lives  in  the  house. 

Period  of  Infectivity. — It  is  well  to  "consider  all  patients  in- 
fectious so  long  as  they  present  the  clinical  features  of  the 
disease. 

Death-rate. —  The  death-rate  of  Kala  Azar  varies  on  an 
average  between  75  and  96  per  cent,  where  the  disease  is 
epidemic.     Among  sporadic  cases  the  mortality  may  be  much 

less. 

Home  Prophylaxis. — All  cases  of  Kala  Azar  should  be  con- 
sidered as  infectious  and  should  be  isolated.  No  patients  in 
Hospital  ought  to  be  allowed  to  wear  their  own  clothing.  All 
clothing  which  has  been  in  contact  with  the  patient  should  be 
destroyed.  The  greatest  care  should  be  taken  to  eradicate 
vermin  from  the  house,  especially  bed-bugs,  and  when  or- 
dinary means  fail  a  thorough  stripping  and  even  the  re- 
building of  the  house  should  be  undertaken.  The  strictest 
personal  and  domestic  cleanliness  is  necessary. 

Public  Health  Administration.  —  All  infected  houses  and 
"  lines  "  should  be  dealt  with  and  if  necessary  destroyed.  As 
the  disease  occurs  in  India  and  the  Soudan  there  is  little 
difficulty  in  destroying  the  flimsy  houses  and  rebuildini>^ 
in  a  different  place.  An  energetic  campaign  ought  to  be 
directed  against  the  bed-bug — the  houses  should  be  fumigated 
with  burning  sulphur  or  liquid  S0„,  beds  should  be  thoroughly 
washed  with  a  boiling  solution  of  1-20  carbolic  acid  or  1-1000 
perchloride  of  mercury,  and  all  clothing  and  blankets  should 
be  destroyed.  Habits  of  personal  and  domestic  cleanliness 
should  be  inculcated  amongst  the  natives  as  far  as  possible. 


Q     ^ 


FEVERS    OF 
UNCERTAIN    BACTERIOLOaY. 


Chapter  XV. 

SCARLET    FEVER. 

Synonyms :      Scarlatina. 

Fr.  :      Scarlatine. 
Ger.  :      Scharlacli. 

Definition.  —  An  acute  specific  infectious  fever,  cliarac- 
terisecl  by  sudden  onset,  a  characteristic  eruption,  and  a  well- 
marked  lesion  in  the  throat. 

Incubation  Period. — The  incubation  period  of  scarlet  fever 
is  short,  varying  between  one  and  seven  days.  The  usual  in- 
cubation is  2-4  days. 

Rash. — When  typically  developed  the  rash  of  scarlet  fever 
is  easily  recognised,  but  in  none  of  the  eruptive  fevers  does 
the  rash  present  so  many  variations  and  modifications,  both 
in  character  and  distribution,  as  in  scarlatina.  The  rash  is 
essentially  a  punctiform  erythema,  consisting  of  small  closely- 
set  bright  red  points  on  a  ground  of  paler  red.  It  appears 
about  twenty-four  hours  after  the  onset  of  symptoms,  becom- 
ing visible  first  on  the  sides  of  the  neck  and  upper  part  of  the 
chest  and  spreading  gradually  over  the  whole  body,  involving 
the  legs  and  feet  last  of  all.  While  it  is,  in  typical  cases, 
very  general  in  its  distribution,  the  palms  of  the  hands  and 
soles  of  the  feet  do  not  show  punctation,  although  they  may 
be  deeply  flushed.  The  back  and  upper  part  of  the  chest  are 
often  so  deeply  flushed  that  the  punctae  cannot  be  readily  dis- 
tinguished, while  on  the  abdomen  the  punctse  can  often  be 
seen  as  bright  points  on  a  skin  that  is,  perhaps,  only  rather 
yellower     than     normal,     or     onh^     faintly     flushed.  On 

the  forearm   and   front  of  the   legs,    the   rash   is   seldom   so 


Scarlet  Feoer.  217 

iiinfoi'iiily  (listril)ute(l  us  elsewhere  (jii  llie  body,  iiiid  lends  to 
assume  a  patchy  and  rather  indeterminate  character,  while 
ill  these  reg-ions,  also,  it  is  frequently  quite  definitely  papular. 
This  papular  character  is  particularly  evident  on  the  front  of 
the  legs  about  the  shins,  and  may  help  g-reatly  in  the  diag- 
nosis of  a  case  of  scarlet  fever  when  the  patient  has  come 
under  observation  after  the  rash  has  begun  to  fade.  Many 
people  describe  the  face  in  scarlet  fever  as  being  merely 
flushed  and  not  invaded  by  the  rash,  but  in  most  cases  with 
a  well-developed  rash  it  will  be  seen  that  the  punctiform 
erythema  does  invade  the  face  in  the  lateral  aspect,  spreading 
up  a  little  from  the  angle  of  the  jaw,  and  the  forehead  is  also 
frequently  invaded,  although  the  malar  region  shows  no 
IDunctce  but  is  merely  flushed.  Pressure  of  the  fingers  over 
an  area  of  skin  invaded  by  the  eruption  temporarily  blanches 
the  part,  but  the  marks  left  by  the  fingers  are  distinctly 
reddish  yelloAV  and  not  white  like  similar  marks  left  after 
pressure  over  a  flushed  area  in  health. 

The  rash  also  invades  the  soft  palate,  and,  indeed,  this 
may  be  the  first  situation  where  it  is  visible.  In  addition  to 
the  usual  faucial  and  tonsillar  congestion  the  punctate  char- 
acter of  the  rash  is  sometimes  very  striking  on  the  soft  palate 
and  may  aid  considerably  in  the  early  diagnosis  of  a  case  of 
scarlatina. 

Red  staining,  which  does  not  disappear  on  pressure,  is 
often  visible  along  the  lines  formed  by  the  natural  folds  of 
the  skin,  particularly  in  the  neck  and  in  the  flexures  of  the 
elbow  and  knee. 

A  miliary  eruption  frequently  appears  as  a  result  of  the 
hyperaemia  of  the  skin,  and  numberless  tiny  vesicles  are  visible, 
particularly  on  the  neck  and  chest,  apparently  over  the  site 
of  the  punctxe.  These  dry  up  and  rupture,  leaving  small  pin- 
point openings  which  may  be  the  starting  point  of 
desquamation. 

The  scarlatinal  rash  begins  to  fade,  as  a  rule,  about  the 
fourth  day,  and  has  mostly  disappeared  at  the  end  of  a  week. 

The  eruption  is,  however,  not  always  so  typical.  It  may 
appear  otx\j  on  the  neck  and  chest,  leaving  the  rest  of  the  body 
free;  it  may  present,  in  certain  grave  cases  with  severe  early 


218  Chapter  XV. 

toxaemia,  a  dusky  blotchy  appearance  with  no  regularity  of 
distribution  and  with  none  of  the  punctate  character  met 
with  in  the  typical  eruption ;  in  some  malignant  cases  it  is 
altogether  absent;  in  many  mild  cases  it  is  represented  by  a 
faint  blush,  limited  to  the  neck,  back  and  chest,  or  of  fairly 
general  distribution,  which  may  fade  in  a  few  hours  leaving 
no  apparent  trace  behind.  In  the  mild  cases,  however,  while  the 
rash  has  been  faint  and  evanescent,  papules  may  persist  in  the 
region  of  the  shins  which  may  afford  a  certain  help  in  diag- 
nosis. In  a  few  cases  the  blotchy  character  of  the  rash  which 
is  so  common  on  the  legs  is  apparent  also  on  the  thighs,  arms 
and  back,  and  the  case  may  be  extremely  difficult  to  distin- 
guisli  from  a  rather  aberrant  type  of  measles. 

In  certain  severe  toxic  cases  petechise  appear,  either  alone 
representing  the  rash,  or  in  association  with  a  badly-developed 
and  dusky  punctiform  erythema  of  quite  irregular  distribution. 

As  the  rash  fades,  or  just  as  it  has  faded,  desquamation 
of  the  cuticle  occurs.  This  begins  as  a  powdery  desquamation 
on  the  face  and  lobes  of  the  ears  somewhere  about  the  fourth 
or  fifth  day  after  the  appearance  of  the  rash.  Then  small 
"  pinholes  "  appear  on  the  neck,  upper  part  of  the  chest  and 
upper  arm,  usually  from  the  seventh  to  the  tenth  day.  The 
process  spreads  downwards  over  the  trunk  and  arms  and  the 
hands  begin  to  show  desquamation  about  a  fortnight  after 
the  onset  of  illness  and  the  feet  about  a  week  later.  As  a 
general  rule  desquamation  is  complete,  save  on  the  palms  and 
soles,  about  four  weeks  after  the  onset  of  the  disease,  and 
the  palms  are  usually  free  at  the  end  of  the  fifth  week.  The 
tough  skin  of  the  soles  of  the  feet,  however,  has  seldom  com- 
pletely separated  until  the  end  of  the  sixth  or  eighth  week, 
and  may  not  desquamate  completely  until  the  tenth  or  twelfth 
week  of  the  disease.  Occasionally  the  skin  separates  in  large 
sheets  on  the  back  and,  still  more  rarely,  may  be  shed  from 
the  feet  and  hands  in  the  shape  of  complete  casts  of  the  ex- 
tremities, like  gloves.  After  desquamation  is  complete,  a 
secondary  desquamation  may  occur,  either  general  in  distribu- 
tion, or  more  commonly  confined  to  the  hands  and  feet. 

The  dates  of  desquamation  given  above  are  only  rough 
averages.     In    many    cases    desquamation    may    be    complete. 


Scarlet  Fever.  219 

save  on  the  hands  and  feet,  within  a  fortniglit,  while  in  other 
cases,  usually  mild,  desquamation  may  not  appear  anywhere 
until  about  the  fourth  or  fifth  week  of  tlie  disease.  It  is 
sometimes  so  slight  as  to  be  practically  imperceptible,  and 
in  many  mild  cases  all  that  can  be  seen  is  a  little  powdery 
desquaimation  at  the  anterior  borders  of  the  axilla),  at  the 
root  of  the  neck  and  in  the  groins,  and  a  little  roughness  of 
the  shins  with  some  powdery  desquamation  between  the  fingers 
and  between  the  toes.  As  is  the  case  with  all  the  manifesta- 
tions of  scarlet  fever,  desquamation  may  be  so  profuse  and 
typical  as  to  be  impossible  to  miss,  or,  on  the  other  hand, 
so  slight  mid  atypical  as  to  afford  no  belp  in  t})e  diagnosis  of 
the  case,  save  only  in  conjunction  with  other  signs  and 
symptoms. 

Clinical  Types. — It  is  usual,  in  describing  the  various 
types  of  scarlatina,  to  mention  the  ordinan^  ^^jpe?  or  scarlatina 
simplex;  the  malignant  type;  the  type  in  which  pyogenic 
manifestations  in  the  throat  constitute  the  chief  feature  of 
the  attack  or  scarlatina  anginosa;  and  the  mild  type.  It  must 
be  remembered,  however,  that  although  many  cases  can  be 
accurately  classified  under  one  or  other  of  these  headings,  one 
meets  cases  which  are  on  the  border  line  of  two  classes,  and 
one  may  have  difficulty  in  labelling  them  as  simple  or 
anginous,  as  anginous  or  malignant,  as  simple  or  mild,  but  so 
long  as  it  is  understood  that  such  classifications  are  used 
merely  for  convenience,  and  are  not  accurate,  it  is  well  to 
adhere  to  the  accepted  grouping  of  the  various  types. 

Scarlatina  Simplex. — The  onset  is  sudden  and  acute.  The 
attack  may  be  ushered  in  by  headache,  vomiting,  rigor  and 
sore  throat  occurring  almost  simultaneously;  or  sore  throat, 
with  a  feeling  of  heaviness  and  slight  general  malaise,  may 
precede  the  headache,  vomiting  and  sensation  of  chill  by  some 
hours.  A  convulsion  may  take  the  place  of  rigor  in  young 
children.  The  sore-throat  increases  rapidly  in  severity,  the 
tonsils  enlarge,  the  mucous  membrane  of  the  nose  and  naso- 
pharynx may  decome  dry  and  turgid,  so  that  the  patient  com- 
plains of  a  "  swollen  "  sensation  at  the  back  of  the  nose  and 
probably  breathes  by  the  mouth.  The  tongue  becomes  rapidly 
coated  with  a  white  fur,  and  exudate  appears  on  the  tonsils. 


220  Chapter  XV. 

There  is  pain  and  tenderness  over  the  cervical  glands,  which 
in  most  cases  can  be  felt  to  be  slightly  enlarged.     Pain   in 
swallowing  is  a  common  feature  of  the  disease  at  this  stage. 
Appetite  is  absent,   but  the  patient  feels  very  thirsty.        In 
about  twenty-four  hours  the  rash   develops.      The  appearance 
of  the  face  is  very  characteristic.     It  is  flushed   save  for   a 
circumoral   ring   of   comparative   pallor.     The   e^-es   are   com- 
monly blood-shot,  and  the  punctiform  rash  is  visible  on  the 
temples  and  at  the  angles  of  the  jaw.     Although  the  eyes  are 
bloodshot,  there  is  none  of  the  lachrymation  and  photophobia 
which  are  so  common  in    measles.       The    temperature    rises 
quickly  to  high  registers  from  the  commencement  of  the  ill- 
ness, and  the  pulse  is  rapid,  full  and  bounding,  the  pulse-rate 
being  unusually  rapid  in  proportion  to  the  rise  in  tempera- 
ture.    The  patient  may  be   delirious   almost   from  the  onset 
of  the    illness    and    is    usually    restless    and    uncomfortable, 
sleeping  only  for  short  periods  at  a  time  and  complaining  of 
pain  in  the  throat,   headache   and   general   uneasiness.        In 
about  three  days  the  headache  disappears,  the  throat  symp- 
toms abate,  the  tendency  to  delirium  lessens,  the  fever  shows 
larger  remissions,  and  towards  the  end  of  the  first  week  the 
temperature  falls  by  rapid  lysis,  with  a  corresponding  drop 
in  the  pulse-rate  to  normal.     As  the  temperature  falls,  the 
swelling  and  acute  congestion  of  the  throat  disappear,  but  a 
certain  amount  of  undue  redness  of  fauces  and  tonsils  may 
persist  for  weeks.     The  tongue  which  is  at  first  coated  with 
a  thick  creamy  fur  presents,   about  the  second  or  third  day 
of    fever,    the    typical     "  strawberry "     appearance,    due    to 
the  projection  of  swollen  papillae  through  the  fur.     As   the 
temperature  falls  the  tongue  grows  clean,  and,  after  the  fur 
disappears,    has    a    raw    rough    appearance,    with    enlarged 
papillae  projecting  from  the  surface.      As  desquamation  pro- 
ceeds the  tongue  verj^  often  has  a  smooth  glazed  look.     In  un- 
complicated cases  of  scarlatina  simplex  the  patient's  troubles 
are  now  mainly  over  and  he  has  only  to  look  forward  to  a 
somewhat  lengthy  convalescence  regulated  by  precautions  for 
his  own  safety  and  against  his  infecting  others. 

Scarlatina  Maligna  presents  a  very  different  picture.      In 
its   fulminant  type   a   patient   may   be   suddenly   seized   with 


Scar  I  ft  Fener.  221 

headache,  rigor,  vomiting  and  high  fever,  becoming  wildly 
delirious,  and  shortly  afterwards  comatose,  <i,nd  dcalli  may 
ensue  within  twenty-four  hours  without  the  develo^jment  of 
rash  or  any  visible  throat  manifestation  beyond  a  little  faucia! 
redness.  In  some  cases  vomiting  and  diarrhwa  are  the  most 
clamant  symptoms  and  persist  till  death  occurs.  The  ful- 
minant type  is  very  rare  at  the  present  day,  but  it  is  occa- 
sionally met  with.  In  one  case  which  occurred  in  my  own 
practice,  a  child  of  eight,  previously  healthy,  was  infected  by 
her  brother  who  had  a  very  mild  attack  of  scarlet  fever,  and, 
four  days  after  the  onset  of  her  brother's  illness,  she  was  sud- 
denly seized  with  headache,  hyperpyrexia  and  severe  vomit- 
ing. She  rapidly  became  comatose,  and  died  in  twenty-six 
hours  after  the  first  appearance  of  fever  and  headache.  In 
this  case  the  fauces  and  tonsils  were  distinctly  congested,  the 
tongue  was  thickly  coated,  and  tw^o  hours  before  death  some 
deep  livid  blotches  appeared  about  the  neck  and  anterior 
borders  of  the  axillse.  An  examination  of  the  body  was  made 
post  Tnortem,  and  no  meningitis  or  other  gross  lesion  w-as 
found. 

In  other  malignant  cases  death  is  delayed  for  some  days, 
but  few  patients  who  are  attacked  by  a  truly  malignant  form 
of  the  disease  survive  beyond  three  days.  The  striking  feature 
in  such  cases  is  the  apparent  insignificance  of  the  local  lesion 
in  the  throat.  The  fauces  and  tonsils  may  be  congested,  but 
there  is  little  swelling  of  the  parts  and  no  exudate.  If  the 
patient  survives  longer  than  twenty-four  hours  an  imperfectly 
developed  rash  may  be  visible,  affecting  the  neck,  chest,  back, 
groins  and  thighs,  showing  little  of  the  punctiform  character 
which  is  so  typical  in  the  properly-developed  rash,  but  being 
rather  blotchy  and  livid,  with  petechias  at  the  axillary 
borders  and  in  the  groins.  Sleeplessness  and  a  restless  de- 
lirium may  be  troublesome  in  these  cases,  which  are  invari- 
ably fatal.  Convulsions  may  occur  at  frequent  intervals  and 
vomiting  may  be  almost  constant.  Profuse  diarrhoea  is 
sometimes  met  with. 

In  yet  another  kind  of  malignant  attack,  fever  may  be 
moderate  and  there  may  be  little  restlessness  and  delirium, 
but  the  heart  is  evidently  profoundly  poisoned  from  the  first 


222  Chapter  XV. 

by  the  toxins  of  the  disease.  The  patient  has  a  rapid,  soft, 
irregular  pulse,  the  ventricular  sounds  are  faint  at  the  apex 
and  practically  inaudible  at  the  base,  the  skin  presents  a 
livid  pallor  and  respiration  tends  to  be  "sighing"  in  char- 
acter. In  such  cases  death  occurs  about  the  fourth  or  fifth 
day.     Vomiting  and  diarrhoea  are  often  severe. 

Scarlatina  Anginosa,  or  septic  scarlet  fever,  is  the  name 
given  to  that  type  of  case  in  which  the  throat  manifestations 
are  unusually  severe;  in  which,  if  the  patient  lives  long 
enough,  there  is  sloughing  of  the  tonsils,  uvula  or  fauces 
generally,  and  in  which  abscess  in  the  tonsil,  post-pharyngeal 
abscess,  "  collar-neck  "  and  other  manifestations  of  an  acute 
pyogenic  infection  are  frequently  met  with. 

The  onset  of  such  a  case  is  commonly  severe  and  acute. 
Prom  the  commencement  the  throat  is  very  markedly  in- 
volved; the  tonsils  enlarge,  sometimes  enormously,  the  uvula 
and  fauces  generally  are  swelled,  and  the  whole  throat  has 
an  angry  look  and  is  usually  deep  purplish-red  in  colour.  The 
tonsils  may  be  covered  with  much  mucopurulent  exudate,  or 
may  appear  smooth  and  glared,  with  only  a  small  amount  of 
exudate  on  their  surface.  The  glands  at  the  angle  of  the  jaw, 
and  in  the  cervical  region  generally,  are  swelled,  painful  and 
tender,  and  the  skin  overlying  them  may  very  soon  become 
reddened  and  infiltrated.  In  such  cases  the  rash  is  com- 
monly profuse  and  well  developed,  perhaps  a  little  darker 
than  is  usual  in  a  simple  case,  but  it  may  come  out  in  patches, 
and  be  slow  of  appearance.  It  is  not  infrequentlj^  of  a  rather 
livid  colour  and  may  show  a  tendency  to  be  "fixed"  in  parts, 
and  definite  petechise  may  be  seen. 

During  the  first  few  days  of  a  severe  attack  of  septic 
scarlet  fever,  nervous  symptoms  are  often  very  urgent.  The 
patient  is  sleepless  and  delirious  at  night,  restless  and  dis- 
turbed during  the  day  by  pain  in  the  head  and  throat  and  by 
the  swelling  of  the  tonsils  and  uvula.  The  greatest  trouble 
may  be  experienced  in  procuring  rest  for  him,  and  no  pains 
must  be  spared  by  the  physician  to  induce  sleep  and  make  the 
patient  more  comfortable,  as  it  is  largely  on  the  success  of  his 
efforts  in  this  direction  that  the  life  of  the  patient  depends. 


Scarlet  Fever.  223 

There  is  always  a  certain  amount  of  slouf^hing  of  the  ton- 
sils, and  the  process  is  in  some  cases  very  extensive,  involving 
both  tonsils,  the  uvula,  the  pillars  of  the  fauces  and  even 
the  soft  palate.  An  abscess  may  form  in  the  substance  of  the 
tonsils  leaving  a  ragged  foul  ulcerating  cavity  where  it  bursts 
or  is  opened.  Sloughing  or  abscess  formation  appears  about 
the  fourth  or  fifth  day,  and  several  weeks  may  elapse  before 
the  throat  is  completely  healed. 

The  temperature  as  a  rule  runs  high  in  scarlatina 
anginosa,  and  fever  is  of  longer  duration  than  in  a  simple 
case.  Even  without  the  occurrence  of  any  definite  complica- 
tion the  temperature  does  not  fall  to  normal  about  the  end 
of  the  first  week  but  fever  may  continue  for  ten  days  to  a  fort- 
night, or  even  longer,  depending  largely  on  the  condition  of 
the  throat. 

Death  may  occur  during  the  first  week,  before  there  is 
much  ulceration  of  the  tonsils,  or  it  may  occur  during  the 
period  of  sloughing  and  abscess  formation,  or  it  may  result 
from  one  or  other  of  the  more  serious  complications,  which  are 
particularly  liable  to  appear  in  connection  with  the  anginous 
form  of  the  disease. 

Mild  forins  of  Scarlet  Fever  are  met  with  where  the  mani- 
festations of  the  disease  are  so  slight  that  unless  they  occur 
in  association  with  other  definite  attacks,  their  recognition  is 
a  matter  of  extreme  difficult}-.  Slight  headache  and  sore 
throat,  with  almost  no  fever,  followed  on  the  same  day  or  on 
the  next  day  by  a  faint  and  transient  erythema,  perhaps  of 
very  limited  distribution,  may  be  all  the  symptoms  which 
indicate  disease,  and  examination  of  the  throat  may  reveal 
nothing  save  a  little  faucial  and  tonsillar  congestion.  In  a 
couple  of  days  all  symptoms  may  disappear,  and  the  conges- 
tion of  the  throat  may  be  as  short-lived  as  the  general  symp- 
toms. In  certain  of  these  cases,  however,  a  red  tongue  with 
enlargement  of  the  papillae  may  give  the  key  to  the  puzzle, 
but  in  others  there  is  nothing  for  it  but  to  wait  for  desquama- 
tion to  confirm  a  tentative  diagnosis  of  scarlatina.  Des- 
quamation is  frequently  long  delayed  in  mild  cases,  and  shows 
as  nothing  more  than  a  fine  powder,  best  seen  on  the  neck,  the 
anterior  axillary  borders,  the  shins,  and  between  the  fingers 


224  Chapter  XV. 

and  toes.  It  may,  indeed,  be  as  difficult  to  pronounce 
definitely  as  to  the  desquamation  being-  scarlatinal  as  to  make 
a  diagnosis  during  the  first  days  of  illness. 

Another  type  of  mild  case  which  presents  great  difficulties 
in  diagnosis  is  the  type  where  mild  throat  manifestations  are 
accompanied  by  no  rash,  or  at  any  rate  have  associated  with 
them  an  eruption  so  slight  and  evanescent  that  when  the 
jDatient  is  seen  by  a  physician  even  on  the  first  and  second 
days  of  illness  it  has  disappeared,  without  attracting  the 
attention  of  those  in  immediate  attendance. 

Slight  and  transient  rashes,  seldom  showing  any  puucta- 
tion,  are  practically  impossible  to  distinguish  from  a 
generalised  febrile  flushing,  unless  they  are  much  more  dis- 
tinct on  the  neck  and  upper  part  of  the  chest  than  elsewhere 
over  the  body,  or  have  definitely  raade  their  first  appearance 
in  these  regions  before  spreading  elsewhere,  or  when,  as  is 
least  common,  the  erythema  is  confined  entirely  to  the  neck 
and  upper  part  of  the  chest,  the  back,  upper  arms  and  thighs. 

Even  in  the  very  mild  cases  when  no  rash  has  been 
observed,  slight  desquamation  may  follow  some  weeks  after 
the  onset  of  the  illness,  but  in  a  large  number  of  such  cases  a 
diagnosis  of  scarlet  fever  can  be  made  only  on  the  occurrence 
of  an  acute  nephritis  or  some  other  complication  of  the  disease, 
or  when  it  is  followed  by  undoubted  cases  of  scarlatina  among 
those  who  have  been  closely  associated  with  the  patient. 

Complications. —  In  the  absence  of  any  certain  knowledge  of 
the  caiisal  agent  of  scarlet  fever,  it  is  difficult  to  classify  the 
complications.  Some  may  be  due  directly  to  the  specific 
organism,  while  others  are  certainly  due  to  a  secondary  infec- 
tion by  the  pyogenic  organisms,  streptococci,  staphylococci 
and  the  pneumococcus.  It  is  during  the  course  of  the 
"  septic  "  or  '"  anginous  "  type  of  the  disease  that  most  of 
the  commoner  complications  arise,  especially  those  of  a  sup- 
purative kind,  directly  due  to  the  sloughing  and  suppurating 
throat.  Generally  speaking,  granted  that  equal  care  is  taken 
of  the  patients  during  the  first  four  or  five  weeks  of  the 
disease,  the  more  severe  the  case,  the  more  likely  is  it  that 
complications  will   occur,    but  it   must  be   remembered  that   a 


Scarlet  Fecer.  '22r) 

very  mild  case,  if  carelessly  handled,  may  develop  complica- 
tions of  great  gravity,  wliicli  uniy  result  in  a  fatal  termination. 

The  common  complications  are  cervical  adenitis;  rfdrnti.'i; 
otitis  media;  mastoid  fjeriostitis;  abscess  in  the  'mastoid  hone; 
2)ost-i)haryngeal  abscess;  "  collar  neck  ";  suirpuratioe  arth- 
ritis; periostitis;  affections  of  the  heart  and  pericardima; 
^^scarlatinal  rJieuntatisni,  '\-  acute  nephritis;  pleurisy;  jaun- 
dice ;  and  diarrJioL'a. 

Cervical  adenitis  in  a  mild  form  is  extremely  common ; 
in  fact,  some  enlargement  of  glands  about  the  angle  of  the  jaw 
is  tlie  rule  rather  than  the  exception  in  all  cases  of  scarlet 
fever  where  there  is  any  marked  implication  of  the  throat, 
but  in  severe  simple  and  anginous  types  of  the  disease  the 
adenitis  is  sometimes  very  acute  and  extensive,  affecting  the 
glands  in  the  anterior  triangle  as  well  as  those  at  the  angle 
of  the  jaw.  The  affected  glands  are  large,  painful,  tender 
and  matted  together,  and  in  bad  cases  the  overlying  skin 
becomes  infiltrated  and  reddened.  More  or  less  suppuration 
of  the  affected  glands  is  common,  and  the  resulting  abscess  is 
often  large  and  associated  with  considerable  sloughing  of  the 
skin  and  soft  tissues  of  the  neck.  Adenitis  appears  usually 
about  the  third  or  fourth  day  of  illness,  but  suppuration  is 
not  commonly  apparent  until  some  time  between  the  seventh 
and  fourteenth  day. 

Rhinitis  is  a  frequent  and  troublesome  complication,  and 
is  found  in  severe  simple  and  anginous  cases.  It  appears 
towards  the  end  of  the  first  week  of  illness.  The  nose  feels 
dry  and  irritable,  and  very  soon  swelling  of  the  mucous  mem- 
brane occurs  with  resulting  mouth-breathing.  A  thin  sanio- 
sanguinolent  discharge  flows  from  the  nose,  which  excoriates 
the  skin  at  the  edge  of  the  nostrils  and  also  the  upper  lip. 
The  discharge  becomes  mucopurulent  and  scabs  form  on  the 
nasal  mucous  membrane  which  tend  to  separate  when  the 
nose  is  blown  or  cleared,  and  some  blood  flows  after  their 
separation.  Sometimes  considerable  epistaxis  results  from 
the  rhinitis.  Scabbing  in  the  nostrils  and  an  irritating  dis- 
charge from  the  nose  often  persists  for  weeks,  and  the  condi- 
tion is  extremely  liable  to  relapse  and  thus  prolong  convales- 
cence.    A    scarlatinal    rhinitis    is    often   the   beginning   of    a 


226  Chapter  XV. 

clirouic  uasal  aud  post-nasal  catarrh  with  hypertrophy  of 
the  turbinates  and  of  the  mucous  membrane  of  the  naso- 
pharynx. 

Otitis  Media  is  met  with  not  infrequently  in  cases  of  the 
anginous  type,  and  is  probably  due  to  a  direct  infection  by 
way  of  the  eustachian  tube.  Like  the  other  suppurative  com- 
plications, it  occurs  somewhere  between  the  seventh  and  four- 
teenth day  of  illness,  and  may  or  may  not  be  associated  with 
much  pain.  In  some  cases  the  escape  of  a  little  purulent  dis- 
charge from  the  external  meatus  may  be  the  first  indication  of 
any  ear  infection,  while  in  others  the  patient  may  suffer  from 
severe  pain  in  the  ear  for  some  days,  when  no  operative  inter- 
ference is  made,  before  the  tympanic  membrane  ruptures  and 
relief  comes  with  the  escape  of  pus.  In  such  cases  when  there 
is  much  pain  in  the  ear,  the  membrane  is  seen  to  be  distinctly 
injected  and  may  bulge  outwards. 

Mastoid  periostitis  is  met  with  most  commonly  in  con- 
junction with  some  degree  of  sup2)uration  in  the  middle  ear. 
There  is  swelling  and  redness  behind  the  ear,  and  it  is  not 
uncommon  in  children  for  the  abscess  which  usually  results 
from  the  periosteal  inflammation  to  discharge  into  the 
meatus.  It  is  not  in  itself  a  serious  condition  and  yields 
rapidly  to  surgical  treatment. 

Ahscess  in  the  Mastoid  Bone  is  an  exceedingly  rare  com- 
plication of  the  acute  stage  of  scarlet  fever,  and  is  usually 
found  in  those  patients  who  have  had  some  previous  middle- 
ear  inflammation  of  a  chronic  kind. 

Post-pharyngeal  abscess  sometimes  arises  in  connection 
with  an  anginous  attack  and  may  be  attended  with  grave 
danger.  In  all  cases  where  there  is  any  collection  of  pus  in  the 
tonsil  or  much  sloughing  of  the  throat,  the  posterior  pharyn- 
geal wall  should  be  carefully  watched  for  the  bulging  which 
is  suggestive  of  the  formation  of  a  post-pharyngeal  abscess,  as, 
if  it  is  allowed  to  burst,  the  patient  is  exposed  to  danger  from 
suffocation,  septic  pneumonia,  or  a  generalised  pyaemia  from 
the  swelling  of  the  pus.  Unless  the  abscess  is  drained  early, 
the  damage  done  by  its  burrowing  in  the  soft  tissues  may  be 
extensive,  and  I  have  seen  one  case  where  severe  and  fatal 


Scarlet  Fever.  227 

haemorrhage  occurred  from  the  ulceration  and  rupiuro  of  an 
arterial  branch . 

'^Collar-neck"  is  a  brawny  infiltration  of  tfie  neck  due  to 
a  streptococcal  infection,  similar  to  the  condition  known  as 
angina  ludovici  which  may  arise  apart  from  an  attack  of 
scarlet  fever.  The  neck  is  swelled  and  reddened,  and  the 
swelling  is  of  a  very  firm  consistency.  The  swelling  is  sug- 
gestive of  a  thick  collar  round  the  neck  and  may  be  so  extreme 
that  the  hollow  between  the  point  of  the  chin  and  the  sternum 
may  be  quite  lost.  The  condition  is  a  dangerous  one  and 
requires  prompt  interference.  It  is,  fortunately,  a  rare  com- 
plication ;  it  appears  towards  the  end  of  the  first  week,  usually 
in  association  w'lih.  an  anginous  attack. 

Suppurative  arthritis  is  another  dangerous  complication, 
which  sometimes  makes  its  appearance  during  the  second  or 
third  week  of  a  severe  "  septic  "  attack  of  scarlet  fever.  The 
knees  and  elbows  are  the  joints  most  frequently  attacked,  and, 
in  marked  distinction  from  the  arthritis  of  a  ''rheumatic  " 
type,  only  one  joint  is  usually  affected.  The  symptoms  are 
pain,  not  usually  severe,  swelling,  redness  and  oedema  round 
the  affected  joint.  The  swelling  is,  in  the  first  instance,  peri- 
articular. Within  twenty-four  or  thirty-sis  hours,  however, 
fluid  appears  in  the  joint,  and  great  destruction  of  tissue  may 
result.  The  fluid  is  either  sero-purulent  or  frankly  purulent 
in  character. 

Periostitis  or  osteomyelitis  of  one  or  other  of  the  long- 
bones  is  not  very  uncommon,  and  presents  the  ordinary  pic- 
ture of  such  acute  conditions,  save  that,  as  in  suppurative 
arthritis,  the  condition  is  attended  with  much  less  pain  than 
is  usual  in  a  similar  condition  arising  apart  from  scarlet 
fever. 

Affections  of  the  heart  and  pericardium  are  among  the 
most  important  complications  of  scarlet  fever,  although  they 
occur  but  seldom.  Endocarditis  is  the  one  most  frequently 
met  with  and  implicates  the  mitral  valve  with  greatest  fre- 
quency, producing  both  obstruction  and  insufficiency,  but  the 
aortic  valves  also  may  be  affected.  It  has  been  said  that 
endocarditis  always  occurs  in  association  with  an  attack  of 
"scarlatinal  rheumatism,"   but  this  has  certainly  not  been 


228  Chapter  XV. 

my  experience.  Among  the  170  cases  of  ''  scarlatinal  rlieu- 
niatism  "  -which  1  analysed  in  the  (luarfcrly  Jonrital  of 
Medicine,  in  1909,  only  two  cases  of  endocarditis  occurred, 
and  this  did  not  by  any  means  represent  the  total  number  of 
cases  who  suffered  from  endocarditis  among  all  the  admissions 
of  scarlet  fever  to  Belvidere  Hospital  during  the  seven  years 
under  consideration.  It  is  probable,  however,  that  valvular 
lesions  frequently  appear  long  after  the  acute  stage  of  scarlet 
fever  is  over,  so  that  statistics  from  fever  hospitals  throw  but 
little  light  on  the  frequency  with  which  endocarditis  occurs. 

Pericarditis  is  rarely  seen,  but  when  it  does  appear  is 
almost  invariably  fatal.  It  may  be  accompanied  by  effusion 
into  the  pericardial  sac,  either  serous,  sero-purulent  or 
purulent. 

Myocarditis  is  probably  a  fairly  frequent  complication  of 
•severe  attacks  of  scarlet  fever,  and  is  indicated  by  a  weak, 
rapid  and  sometimes  irregular  pulse,  and  faint  ventricular 
sounds,  w^hich  may  be  almost  inaudible  at  the  base.  It  is 
probable  that  the  extreme  tachycardia  which  sometimes  ap- 
pears about  the  end  of  the  second  and  during  the  third  week 
of  the  disease  is  secondary  to  a  myocardial  inflammation. 

''Scarlatinal  rheu7natis7n  "  is  the  name  commonly  given 
to  a  form  of  arthritis  met  with  in  scarlet  fever  at  various 
periods  of  the  attack.  In  the  170  cases  which  I  analysed  and 
Tto  which  I  have  already  made  reference  in  connection  with  the 
occurrence  of  endocarditis,  tlie  aff'ection  occurred  during  the 
first  fortnight  in  125,  or  73  -5  per  cent,  of  the  whole  number. 
More  than  one  joint  is  attacked  as  a  rule,  and  it  is  noticeable 
ihat  in  cases  which  occur  early  in  the  attack  of  scarlet  fever, 
i;he  wrists  and  fingers  are  attacked  in  greater  proportion  than 
other  joints,  and  much  more  frequently  than  in  the  late  cases. 
Early  cases  tend  to  be  more  severe  than  the  late,  both  as 
regards  duration  and  acuteness,  and  appear  commonly  after  a 
high  initial  pyrexia,  an  acutely  inflamed  throat  and  early 
cervical  adenitis.  In  the  late  cases  which  I  observed,  the 
articular  manifestations  were  on  the  whole  mild,  save  where 
ihey  followed  on  the  occurrence  of  a  secondary  tonsillitis,  and 
were  therefore  more  comparable  with  the  usual  type  of  early 
•case. 


Scarlet  Fever.  229 

Tlie  joint  manifestations  are  largely  periarticular, 
always  primarily  so,  and  are  rarely  associated  with  much 
eliusion  into  the  joint  cavity. 

The  "  rheumatic  "  arthritis  of  scarlet  fever  is  extremely 
painful  and,  besides  the  pain  in  the  joints,  patients  often  com- 
plain of  severe  "myalgia." 

Scarlatinal  rheumatism  is  often  associated  with  some 
other  complication  of  the  disease,  such  as  cervical  adenitis, 
otitis  media  or  other  pyogenic  manifestations,  but  there  is  no 
definite  relation  in  point  of  time  between  the  occurrence  of 
joint  pains  and  other  complications;  the  rheumatic  manifesta- 
tions sometimes  precede  the  occurrence  of  other  complications, 
sometimes  succeed  them. 

It  has  been  said  that  the  rheumatism  of  scarlet  fever  is 
true  acute  rheumatism,  and  its  association  with  endocarditis 
and  chorea  has  been  put  forward  as  an  argument  in  favour  of 
this  view.  But  endocarditis  may  be  the  result  of  many  in- 
fections other  than  acute  rheumatic  fever,  and  the  poison  of 
acute  rheumatism  is  not  the  only  poison  which  will  produce 
chorea,  and  I  am  of  opinion  that  the  condition  is  a  "  toxic  " 
one,  comparable  with  the  arthritis  of  serum-disease.  It  may 
be,  of  course,  that  the  non-suppurative  arthritis  of  scarlet 
fever  is  due  to  the  presence  in  the  joints  and  periarticular 
tissues  of  the  specific  organism  of  the  disease,  but  I  have  failed 
to  isolate  any  streptococcus  from  the  joints  in  those  cases  of 
scarlatinal  rheumatism  which  I  have  examined.  It  is  pos- 
sible, however,  that  the  causal  agent  of  scarlet  fever  is 
developmentally  higher  than  the  bacteria,  and  until  its  dis- 
covery it  is  impossible  to  be  definite  on  this  point. 

Painful  nodules  in  the  scalp,  behind  the  ears  and  in  the 
muscles  sometimes  occur  in  association  with  arthritis. 

Acute  nephritis  is  the  most  dreaded  of  the  complications 
of  scarlet  fever,  and  occurs  in  about  five  per  cent,  of  all  cases. 
It  appears  usually  between  the  second  and  fourth  week  of  the 
disease,  during  the  early  part  of  the  period  of  desquamation, 
and,  while  it  occurs  most  commonly  as  a  complication  of  a 
severe  simple  or  an  anginous  attack,  it  may  appear  after  an 
attack  of  scarlet  fever  so  mild  as  to  have  escaped  detection. 
Its  onset  is  frequently  heralded  by  a  rise  in  temperature,  and 


230  Chapter  XV . 

in  the  majority  of  cases  the  temperature  is  elevated  at  some 
time  during  the  first  few  days  of  its  occurrence.  It  has  been 
shown  that  chill  is  the  most  active  exciting  cause  of  scar- 
latinal nephritis.  The  febrile  albuminuria  which  is  so  com- 
monly present  during  the  first  week  of  the  disease  must  not  be 
confused  with  the  true  acute  nephritis  which  occurs,  as  a  rule, 
after  the  initial  fever  has  subsided,  and  after  the  urine  has 
been  free  from  albumin  for  some  time. 

The  first  sign  of  the  onset  of  an  acute  nephritis  is  usually 
the  appearance  of  blood  and  albumin  in  the  urine,  associated 
with  headache,  nausea,  and  frequently  a  rise  in  temperature. 
The  urinary  output  is  low,  and  there  may  even  be  complete 
suppression  of  urine  for  a  time.  The  patient  becomes  oedema - 
tons,  the  face  being  in  most  cases  attacked  first,  ffidema  of 
the  feet,  legs  and  hands  is  very  common,  and  in  some  cases  a 
general  anasarca  may  be  present.  Dropsy  of  the  pleural  and 
peritoneal  sacs  is  sometimes  met  with. 

The  amount  of  blood  in  the  urine  is  commonly  profuse, 
and  it  is,  on  the  whole,  a  favourable  sign  if  the  albumin  is 
apparently  not  much  in  excess  of  what  might  be  roughly  ac- 
counted for  by  the  blood.  It  is  no  unfavourable  sign  to  have 
a  profuse  haematuria  early  in  the  attack,  indeed,  I  have  fre- 
quently found  that  in  cases  where  the  heematuria  is  profuse,, 
the  ureemic  manifestations  are  comparatively  slight  and  the 
duration  of  the  attack  is  not  unduly  prolonged.  The  urine 
has  a  sediment  which  contains  blood-casts,  epithelial  and 
granular  casts  and  numerous  red  blood  corpuscles. 

Headache,  nausea,  vomiting  and  even  convulsions  may 
occur  as  ursemic  manifestations  in  the  course  of  an  acute  scar- 
latinal nephritis,  and  such  manifestations  may  be  far  in  excess 
of  any  of  the  indications  of  acute  nephritis  found  in  the  urine. 
Death  may  occur  as  the  result  of  ursemia,  not  usually  until 
the  acute  nephritis  has  persisted  for  about  a  week,  but  in  one 
case  I  have  seen  death  result,  after  a  series  of  ursemic  con- 
vulsions, on  the  first  day  on  which  albuminuria  was  observed, 
with  only  the  slightest  trace  of  blood  in  the  urine.  It  is  not 
common,  however,  for  death  to  occur  during  the  acute  stage  of 
the  attack ;  the  chief  danger  of  a  scarlatinal  nephritis  lies  in 


Scarlet  Fever.  231 

the  fact  that  it  may  be  the  starting  point  of  a  chronic  renal 
inflammation,  producing,  as  a  rule,  the  large  white  kidney. 
The  great  majority  of  cases  of  scarlatinal  nepliritis,  if  treated 
with  care  and  patience,  result  in  cure,  and  one  cannot  be  too 
careful  in  the  treatment  of  all  cases  which  occur^  having 
regard  to  the  futiire  of  a  patient  who  does  not  make  a  com- 
plete recovery  from  the  acute  attack. 

The  acute  nephritis  of  scarlet  fever  has  been  said  by  some 
to  be  due  to  the  direct  invasion  of  the  kidney  by  a  strepto- 
coccus, and  they  base  their  inference  on  the  fact  that  they  have 
discovered  streptococci  in  the  urine  of  patients  suffering  from 
acute  scarlatinal  nephritis.  Against  this  observation  may  be 
placed  the  observations  made  by  Dr.  Andrew  Love,  for  long 
senior  assistant  physician  in  Belvidere  Hospital,  who  has  per- 
mitted m.e  to  use  his  results  although  they  are  not  yet  pub- 
lished. He  found  that  when  he  took  care  to  sterilise  the 
meatus  and  used  only  specimens  of  urine  drawn  oil  by  a 
sterile  catheter,  he  was  unable  to  recover  a  streptococcus 
from  the  urine  of  patients  suffering  from  acute  scarlatinal 
nephritis,  and  the  natural  inference  is  that  other  observations 
when  catheter-specimens  were  not  used  have  been  vitiated  by 
contamination  from  the  skin.  If  this  view  is  adopted,  it 
will  be  seen  that  acute  nephritis  in  scarlet  fever,  like  arth- 
ritis, may  be  the  result  of  the  action  of  toxins,  and  not  neces- 
sarily due  to  the  direct  invasion  of  the  kidney  by  bacteria, 
although  the  possibility  of  its  being  due  to  the  invasion  of  the 
kidney  by  a  hitherto  unrecognised  organism,  possibly  proto- 
zoal, must  be  acknowledged. 

Pleurisy  is  not  a  common  complication  of  scarlet  fever, 
and  may  occur  at  any  stage  of  the  attack,  from  the  first  week 
until  convalescence  is  well  advanced.  In  some  cases  it  appears 
as  part  of  a  generalised  pyaemia,  and  in  such  cases  may  result 
in  empyema.  In  most  instances,  however,  it  occurs  as  a 
simple,  dry  pleurisy,  of  short  duration,  giving  rise  to  no  par- 
ticular anxiety.  When  pleurisy  with  effusion  occurs,  especi- 
ally during  convalescence,  the  fluid  should  be  carefully 
examined  to  exclude  the  possibility  of  the  pleurisy  being  of 
tuberculous  origin  in  a  person  naturally  susceptible  to  tubercle 

I.'    2 


232  Chapter  XV. 

wiiose  resistance  has  been  further  weakened  by  the  attack  of 
scarlet  fever. 

Jaundice  occasionally  occurs  during  the  course  of  a  severe 
attack  of  scarlet  fever,  but  is  in  itself  of  no  particular  prog- 
nostic significance.  It  is  of  the  ordinary  cataiThal  tj^pe,  and 
usually  yields  readily  to  treatment, 

Diavrhwa  apjDears  not  infrequently  as  a  complication  of 
a  severe  attack,  especially  in  anginous  and  semi-malignant 
cases.     It  may  be  very  profuse,  and  if  so  is  of  grave  import. 

Scarlatina  may  be  complicated  by  other  infectious  diseases, 
of  which  the  more  common  are  diphtheria  and  measles.  It  is, 
j)erhaps,  a  rare  thing  to  have  the  eruption  of  measles  and 
scarlet  fever  practically  synchronous,  but  one  sees  as  an  occa- 
sional rare  curiosity  the  measles  rash  coming  out  just  as  the 
scarlatinal  rash  fades  and  vice  versa.  It  is  more  common  to 
find  that  the  measles  rash  appears  during  the  second  or  third 
week  of  scarlet  fever,  when  it  is  easily  recognised  by  its 
characteristic  appearance  and  distribution,  by  antecedent 
lachrymation  and  coryza  and  by  concomitant  catarrh  of  the 
bronchi  and  lungs. 

The  detection  of  a  coincident  diphtheria  is  often  a  matter 
of  great  difficulty,  and  too  often  it  is  only  recognised  by  the 
occurrence  of  palsj^^,  unexpected  cardiac  failure,  or  by  the 
discovery  of  associated  cases  of  diphtheria.  The  false  mem- 
brane is  frequently  difficult  to  distinguish  clinically  from  the 
sloughing  throat  of  a  severe  scarlatina,  and  when  the  slightest 
suspicion  arises  in  the  physician's  mind  that  the  throat  is  at 
all  suggestive  of  a  diphtheritic  cross-infection,  a  careful  bac- 
teriological examination  should  be  made. 

A  secondary  tonsillitis  is  sometimes  met  with  in  the  third 
or  fourth  week  of  illness  and  even  much  later.  It  has  much 
the  same  character  as  the  primary  throat  affection  of  scarlet 
fever.  In  a  few  cases  it  is  accompanied  by  a  typical  scar- 
latiniform  rash  and  may  indicate  a  true  second  attack  of  the 
disease,  although  the  desquamation  of  the  first  attack  may  not 
be  completed. 

Sequelae, — The  graver  sequelae  of  scarlet  fever  are  chronic 
otitis  media,  valvular  disease  of  the  heart  and  chronic  tubu- 
lar nephritis,  while  of  the  minor  sequelae  may  be  mentioned 


Scarlet  Fever.  233 

chronic  nasal  and  jjost-nasal   catarrh,     and    a    tendency    to 
chronic  inflaTnTnation  of  the  tonsils. 

Chronic  otitis  media  sometimes  results  from  the  acute 
otitis  media  not  infrequently  met  with  as  a  complication,  and 
is  dangerous  in  so  far  a.s  it  may  result  in  a  mastoiditis  and 
cerebral  abscess. 

Valvular  disease  of  the  heart  is  sometimes  met  witli  as  a 
sequel  to  scarlet  fever  even  when  no  murmur  has  been  a]»- 
parent  during  the  attack.  It  is  more  than  possible  that  tin's 
is,  in  many  cases,  a  pure  coincidence,  and  that  the  valvular 
disease  is  due  to  a  cause  quite  unconnected  with  scarlatina, 
but  in  some  instances  the  previous  history  of  the  patient  is  so 
free  from  taint  and  his  general  condition  so  good,  that,  in 
the  absence  of  any  local  infective  focus,  the  valvular  condi- 
tion must  be  considered  to  have  had  its  origin  in  the  attack 
of  scarlet  fever.  The  mitral  valve  is  attacked  with  greater 
frequency  than  any  other. 

Chronic  tubular  nephritis  is  the  most  dangerous  of  all  the 
sequelae  of  scarlet  fever,  and  is  the  direct  result  of  the  acute 
nephritis  which  occurs  during  the  attack.  It  is,  like  ail 
forms  of  chronic  nephritis,  progressive  and  quite  incurable, 
and  from  the  nature  of  the  lesion  which  involves  extensively 
the  secreting  structures  of  the  kidney,  is  more  rapidly  fatal 
than  the  primarily  interstitial  forms  of  the  disease.  Qldema 
of  the  face  and  lower  extremities  is  common  even  at  an  early 
stage,  and  chill,  over-fatigue  or  persistent  errors  in  diet  may 
induce  symptoms  of  uraemia  although  the  condition  may  have 
been  in  existence  for  only  a  few  months. 

Chronic  nasal  and  post-nasal  catarrh,  and  chronic  to7i- 
sillitis  are  not  infrequent  sequelse  of  scarlet  fever  where 
rhinitis  has  been  present  during  the  acute  attack  or  where  the 
inflammatory  process  in  the  tonsils  has  been  severe  and  pro- 
tracted. Such  chronic  inflammations  are  dangerous  in  so  far 
as  the  affected  tissues  are  unhealthy  and  afford  harbourage 
to  micro-organisms  of  all  kinds,  so  that  the  chronically  in- 
flamed mucous  membrane  of  the  naso-pharynx  or  hypertro- 
phied  tonsils  may  form  the  seat  of  primary  infections  which 
may  give  rise  to  multiple  arthritis,  chronic  "  rheumatism," 


234  Chapter  XV. 

or  cervical  adenitis  both  of  a  siinj3le  aud  of  a  tuberculous 
kind. 

Diagnosis. — As  lias  already  been  indicated,  the  diagnosis 
of  a  typical  attack  of  scarlet  fever  is  a  matter  of  ease  and  sim- 
plicity. The  sudden  onset,  high  fever,  disproportionately 
rapid  pulse,  the  development  of  a  punctate  erythematous  rash 
Avith  a  characteristic  distribution,  the  flushed  face,  injected 
sclerotics,  the  circumoral  ring  of  pallor  and  the  typical 
tongue,  with  some  enlargement  of  the  glands  at  the  angle  of 
the  jaw,  all  go  to  make  up  a  picture  that  is  impossible  to  mis- 
take for  any  other  disease.  It  is  where  the  manifestations  are 
aberrant  or  very  slight  that  difficulties  in  diagnosis  arise.  The 
rash  may  be  so  blotchy  as  to  suggest  measles,  or  may  be  very 
slight,  presenting  no  typical  punctation,  but  merely  an 
erythema.  The  throat  may  be  very  slightly  injected,  so  as 
to  suggest  only  an  ordinary  faucial  catarrh,  or  it  may  have 
an  appearance,  even  at  an  early  stage  in  tlie  disease,  closely 
resembling  diphtheria. 

The  conditions  with  which  scarlet  fever  is  most  likely  to 
be  confused  are  acute  follicular  tonsillitis,  the  earlj^  stages  of 
quinsy,  acute  ulcerative  tonsillitis,  diphtheria,  measles, 
German  measles,  and  certain  septic  and  drug  rashes. 

Acute  follicular  tonsillitis  has  an  onset  as  sudden  as 
scarlet  fever,  but  there  is,  on  the  whole,  less  headache  and 
nausea,  and  pains  in  the  limbs  are  very  common.  The  tongue 
is  coated  and  the  tonsils  are  enlarged  and  red.  The  spots  of 
exudate  in  the  crypts  of  the  tonsils  are  very  characteristic, 
and  there  is  but  little  tendency  to  cervical  adenitis.  There 
is  no  rash  beyond,  at  times,  a  slight  erythema  of  the  chest, 
arms  and  back,  which  presents  no  punctation.  The  tempera- 
ture is  high,  but  the  pulse-rate  is  increased  in  fairly  accurate 
proportion  to  the  height  of  the  temperature,  and  is  not  dis- 
proportionately rapid  as  in  scarlet  fever. 

In  the  early  stages  of  a  (juinsy  the  tonsils  are  swelled, 
deep  red  in  colour  and  glazed,  as  in  certain  cases  of  scarlatina 
anginosa,  and  the  tongue  is  usually  coated  with  a  white  fur. 
The  throat  is  painful,  and  there  is  frequently  some  pain  and 
tenderness  in  tlie  cervical  region  with  enlargement  of  glands. 


Scarlet  Fever.  235 

and  the  patient  may  be  delirious.  Otitis  media  is  not  an  un- 
common complication  of  a  quinsy.  If,  liowever,  a  rash  is 
present  in  connection  with  quinsy,  it  is  usually  of  a  definitely 
"septic"  kind,  urticarial  in  character,  aff'ecting  chiefly  the 
elbows  and  knees.  Anything  like  a  general  eruption  is  met 
with  but  seldom,  and  when  it  does  occur  it  is  frankly  ery- 
thematous, with  urticarial  patches,  and  has  nothing  of  the 
punctate  appearance  typical  of  scarlet  fever.  It  may,  how- 
ever, be  a  difficult  matter  to  make  a  diagnosis  between  quinsy 
with  a  blotchy  erythematous  rash  and  scarlatina  anginosa 
accompanied  by  a  blotchy  rash  with  ill-defined  punctation, 
and  it  is  often  necessary  to  await  the  development  of  des- 
quamation before  a  definite  decision  can  be  arrived  at. 

An  ulcerative  tonsillitis,  when  one  or  both  tonsils  are 
inflamed  and  enlarged  and  show  superficial  erosions,  and 
when  there  is  a  definite  enlargement  of  the  cervical  glands 
and  an  erythematous  eruption,  may  be  very  difficult  to  dis- 
tinguish from  scarlet  fever.  The  temperature  may  be  very 
high,  but  the  pulse  rate  is  lower  than  in  scarlet  fever,  and  the 
rash  when  present  is  usually  a  blotchy  erythema  with  a 
sharply  defined  margin,  having  the  usual  distribution  of  the 
septic  rashes. 

Diphtheria  may  sometimes  simulate  scarlet  fever  when 
it  is  complicated  by  a  "septic"  infection — when  the  initial 
fever  is  high,  the  face  flushed,  and  the  throat  presents  a 
generally  infiltrated  and  "dirty"  appearance,  with  no  very 
marked  formation  of  false  membrane.  Here  a  bacterio- 
logical examination  will  frequently  clear  the  matter  up,  and 
it  must  be  remembered  also  that  it  is  a  very  rare  occurrence 
to  have  a  case  of  diphtheria  showing  a  generalised  eruption 
which  is  at  all  like  the  rash  of  scarlet  fever.  Moreover,  even 
in  a  case  of  diphtheria  which  is  complicated  by  an  acute 
streptococcal  infection,  the  pulse-rate  is  seldom  so  rapid  as 
to  suggest  the  possibility  of  scarlatina. 

Measles  is  not  often  difficult  to  distinguish  from  scarlet 
fever,  as  the  catarrhal  symptoms  preceding  the  rash  are 
usually  sufficiently  pronounced  to  render  the  differentiation 
easy,  and  the  blotchy  swollen  face  and  suffused  eyes  of 
measles  form  a  picture  quite  unlike  the  facies  of  scarlet  fever. 


236  Chapter  XV. 

In  a  few  cases,  liowever,  a  badly  developed  measles  rash  may 
be  very  like  a  blotchy  scarlatinal  eruption,  but  while  it  may 
be  difficult  to  decide  from  the  rash  alone  which  disease  is 
present,  a  careful  study  of  the  throat,  and  of  the  history  of 
onset,  the  behaviour  of  temperature  and  pulse,  and  the 
jjresence  or  absence  of  the  bronchial  and  pulmonary  catarrh 
which  is  so  common  in  the  early  days  of  measles,  will  usually 
serve  to  place  the  differential  diagnosis  beyond  doubt. 

Genitan  measles  may  simulate  very  closely  a  mild  attack 
of  scarlet  fever,  especially  that  form  of  it  which  presents  an 
eruption  having  the  character  of  a  punctate  erythema  from 
the  coalescence  of  the  discrete  spots  which  commonly  con- 
stitute the  eruption  of  that  disease.  In  German  measles, 
however,  the  sore  throat  is  trifling  or  may  be  absent,  the  eyes 
are  often  suffused,  and  the  rash  usually  appears  on  the  face  as 
well  as  on  the  trunk  and  limbs,  more  after  the  type  of  the 
rash  in  true  measles.  The  rash  of  German  measles,  too,  is 
apt  to  be  fleeting,  so  that  it  may  appear  first  on  the  face  and 
then  fade  from  that  region  as  the  trunk  is  attacked.  It  tends 
also  to  be  blotchy  on  the  extremities,  although  it  may  be 
fairly  uniform  on  the  body.  While  enlargement  of  the  cer- 
vical glands  is  common  in  German  measles,  such  enlargement 
is  not  suggestive  of  an  acute  inflammatory  process  as  in 
scarlet  fever,  but  the  glands  are  usually  found  to  be  only 
slightly  enlarged  and  are  hard  and  discrete,  while  glandular 
enlargement  is  found  also  in  the  posterior  triangle  of  the 
neck,  the  axillse  and  groins  in  a  large  proportion  of  cases. 

The  fever  of  German  measles  is  usually  low  and  very 
short-lived  and  the  pulse-rate  never  approaches  in  rapidity 
that  commonly  met  with  in  scarlet  fever. 

Septic  rashes  are  occasionally  scarlatiniform  in  charac- 
ter, and  are  frequently  accompanied  by  fever,  but  their 
association  with  a  wound  or  burn  or  some  other  cause  of 
septicaemia  and  the  absence  of  accompanying  sore  throat  make 
their  differentiation  from  scarlatina  an  easy  matter  in  most 
cases.  The  distribution  of  septic  rashes  is  rather  in  the 
neighbourhood  of  joints  than  on  the  trunk. 


Scarlet  Fever.  237 

Drug  rashes  may  also  be  scarlatiniform,  and  tlu;  one 
which  most  resembles  scarlet  fever  is  that  produced  by  bella- 
donna. The  rash  is  erythematous,  and  may  even  be  punctate^ 
the  throat  is  dry  and  injected,  the  face  is  flushed,  the  eyes  are 
bright  and  the  pupils  are  dilated;  there  may  be  some  pyrexia, 
the  pulse  is  very  rapid,  and  delirium  is  nearly  always- 
present.  Desquamation  follows — usually  of  a  fine  powdery 
kind,  but  sometimes  it  has  the  pin-point  character  of  the 
typical  desquamation  of  scarlet  fever.  The  fever  is  very 
transient,  however,  and  although  there  may  be  a  little  dry- 
ness and  redness  of  the  throat,  there  is  no  tonsillar  enlarge- 
ment, while  the  tongue  is  not  at  all  suggestive  of  scarlatina. 

A  rash  may  follow  the  use  of  belladonna  by  the  mouth 
or  in  a  plaster,  or  even  the  instillation  of  atropin  into  the 
eye  for  diagnostic  or  therapeutic  purposes. 

The  erythemata  which  occur  sometimes  after  the  taking- 
of  copaiba,  quinine,  opium,  morphine  and  chloral  hydrate  are 
usually  blotchy  and  show  a  sharply-defined  border  against  the 
healthy  skin,  not  at  all  like  the  gradual  fading  off  of  the 
scarlatinal  rash. 

The  general  symptomatology  of  scarlet  fever  is  what  one 
must  rely  on  in  making  a  diagnosis.  The  bacteriology  of  the 
disease  is  still  doubtful ;  although  certain  members  of  the 
streptococcus  group  and  Schulze's  micrococcus  have  been  put 
forward  as  the  causal  agent  of  the  disease,  it  is  not  wise  at 
present  either  to  deny  or  definitely  afiirm  that  the  specific 
organism  has  yet  been  discovered.  That  many  of  the  condi- 
tions met  with  in  scarlet  fever  are  due  to  the  action  of 
streptococci  or  to  certain  cocci  it  would  be  foolish  to  deny, 
but  it  seems  likely  that  the  micro-organism  which  is  the  actual 
cause  of  the  disease  still  remains  hidden  from  us,  either  on 
account  of  its  size  or  from  its  general  characters,  which  make 
it  impossible  to  cultivate  or  stain  by  any  of  the  methods 
which  we  employ  at  present. 

We  cannot,  therefore,  appeal  to  the  evidence  of  the 
microscope  or  the  culture-growth  when  the  clinical  evidence 
is  scanty;  we  must  depend  entirely  on  the  study  of  the  rash, 
the  general  symptomatology,  the  history  and  association  of 
the  case,  and  on  the  occurrence,  perhaps,  of  some  of  the  more 


238  diaper  XV. 

typical  complications  for  our  diagnosis,  and  even  the  most 
skilled  observers  are  liable  to  be  at  fault  in  the  detection  of 
this  most  protean  disorder,  especially  in  its  early  stages.  It 
is  particularly  in  the  mild  cases  that  difficulties  in  diagnosis 
are  likely  to  occur — M^hen  the  symptoms  of  invasion  are  mild, 
the  rash  is  scanty  and  atypical,  the  fever  and  throat  manifes- 
tations moderate  or  almost  absent,  and  the  general  disturb- 
ance slight. 

The  existence  of  a  pulse-rate  which  is  rapid,  out  of  all 
proportion  to  the  other  manifestations,  and  the  careful  study 
of  the  time  and  appearance  and  the  distribution  of  the  rash, 
the  character  of  the  tongue  and  the  punctate  injection  of  the 
soft  palate  will  help  in  the  formation  of  a  diagnosis,  but  in 
many  cases  one  must  isolate  the  patient  on  suspicion  and 
wait  for  the  occurrence  of  desquamation  before  one  can  say 
definitely  that  the  disease  is  scarlet  fever.  When  a  patient 
is  seen  after  the  rash  has  faded,  the  persistence  of  papules  on 
the  legs  and  the  existence  of  enlarged  papillae  on  the  tongue 
are  often  a  help  in  diagnosis. 

The  earlier  manifestations  of  scarlet  fever  are  sometimes 
so  slight  as  to  escape  notice  altogether,  and  it  is  only  when 
other  cases  occur  from  contact  with  the  patient  or  he  con- 
tracts an  acute  nephritis  that  scarlet  fever  is  suspected,  and 
after  careful  examination  a  little  scurfy  desquamation  on 
the  back,  chest  and  groins  and  some  flaking  of  the  skin 
between  the  fingers  and  between  the  toes  may  be  discovered 
and  make  the  diagnosis  certain. 

In  all  cases  of  acute  nephritis  occurring  in  children  a 
careful  search  should  be  made  for  desquamation  and  the  his- 
tory of  the  case  thoroughly  gone  into,  to  discover  whether  or 
not  the  nephritis  is  a  complication  of  a  hitherto  unrecognised 
case  of  scarlet  fever. 

Treatment. — All  patients  suffering  from  scarlet  fever  must 
be  put  to  bed  and  kept  there  rigidly,  for  at  least  three 
weeks,  preferably  four.  At  first  the  fever,  headache  and 
general  malaise  of  the  patient  make  his  staying  in  bed  a 
necessity  obvious  even  to  the  most  careless  relatives,  but  after 
the  fever  has  declined  and  the  throat  manifestations  have 
subsided,  the  physician  may  have  dilficulty  in  persuading  the 


Scarlet  Fever.  239 

patient  and  liis  friends  that  such  rigid  care  is  absolutely 
necessary,  and  he  should  bluntly  explain  tlie  reasons  for  such 
care  and  show  how  certain  complications,  avoidable  in  most 
cases,  are  prone  to  occur  after  undue  fatigue  or  exposure  to 
surface  chill.  There  is  no  doubt  that  the  incidence  of  late 
arthritis,  endocarditis,  secondary  tonsillitis  and  acute  neph- 
ritis is  lessened  by  the  strict  confinement  of  the  patient  to 
bed  and  by  keeping  him  warm  during  the  first  tliree  or  four 
weeks  of  illness.  This  time  of  rest  in  bed  should  not  be 
shortened  in  a  mild  or  moderate  case,  but  should  be  pro- 
longed where  a  case  has  been  of  a  severe  or  "  anginous  " 
type. 

The  throat  must  be  kept  clean  by  frequent  spraying  with 
a  solution  of  bi-borate  or  bicarbonate  of  soda  or  by  sponging 
it,  when  the  patient  is  too  young  to  spit,  with  cottonwool 
soaked  in  a  similar  solution  and  applied  with  the  finger.  The 
teeth  and  gums  should  be  cleansed  twice  or  thrice  daily  with 
cotton-wool  soaked  in  a  solution  of  glycerine  or  borax  and 
water. 

If  there  is  much  sloughing  or  ulceration  of  the  tonsils, 
a  swab  dipped  in  glycerine  of  carbolic  acid  either  alone  or 
combined  with  glycerine  of  borax  should  be  applied  to  the 
part  gently  but  firmly  twice  or  thrice  in  the  twenty-four  hours 
in  addition  to  the  spraying  and  sponging. 

When  the  tonsils  are  very  red  and  glazed,  as  in  the  early 
stage  of  certain  anginous  cases,  it  is  well  to  be  content  with 
spraying  and  general  light  sponging,  and  not  to  attempt  to 
make  strong  or  firm  applications  to  the  tonsils,  as  they  are 
easily  induced  to  bleed  and  any  rough  handling  causes  the 
patient  a  great  deal  of  quite  unnecessary  suffering. 

Headache  may  be  relieved  by  the  application  of  cloths 
wrung  out  of  cold  or  iced  water  mixed  with  acetic  acid. 

The  bowels  should  be  freely  moved  with  castor  oil  at  the 
beginning  of  the  illness,  and  if  diarrhoea  is  present  a  small 
dose  of  castor  oil,  combined  with  a  small  quantity  of  lauda- 
num or  Battley's  solution  when  the  age  of  the  patient  per- 
mits, may  be  given  daily.  Free  movement  of  the  bowels 
about  the  time  of  the  onset  of  the  fever  tends  to  relieve  head- 
ache and  lessen  the  general  feeling  of  malaise. 


240  diaper  XV. 

The  temperature,  if  running  at  all  liigli,  may  be  con- 
trolled by  tepid  sponging,  but  no  antipyretic  drugs  should 
be  used.  Indeed,  even  sponging  has  its  dangers  before  the 
rash  is  properly  developed,  as  any  surface  chill  is  apt  to 
arrest  the  full  development  of  the  rash. 

Where  the  rash  comes  out  slowly  and  in  patches,  and 
tends  to  be  livid  and  fixed  in  places,  the  patient  should  be 
sponged  or  bathed  with  hot  water  in  which  some  mustard  has 
been  mixed.  I  have  frequently  seen  patients  in  the  early 
stages  of  a  severe  attack  benefit  greatly  from  this  simple  treat- 
ment both  as  regards  the  development  of  the  rash  and  the 
lessening  of  delirium,  headache,  and  other  sjanptoms  of 
toxsemia. 

When  delirium  is  considerable  and  is  not  relieved  by 
cold  applications  to  the  forehead  or  bathing  in  hot  water  and 
mustard  it  is  often  associated  with  great  restlessness  and 
obstinate  sleeplessness.  This  happens  sometimes  in  severe 
"  toxic  "  cases  and  in  the  early  stages  of  the  anginous  type  of 
the  disease,  and  is  a  very  ominous  sign.  Every  effort  must  be 
made  to  induce  sleep  and  many  cases  have  died  from  neglect 
of  this  warning.  The  best  hypnotics  to  employ  are  alcoliol  and 
chloral;  occasional  trioual  and  veronal  given  in  combina- 
tion with  alcohol  are  very  effective.  The  dosage  depends  on 
the  age  of  the  patient.  When  chloral  is  used  it  should  be 
given  in  suitable  doses  repeated  every  hour  until  sleep  i& 
produced,  and  it  is  sometimes  a  good  thing  to  give  a  dose  of 
alcohol  before  beginning  the  chloral  treatment.  Alcohol 
should  be  given  as  whisky  in  hot  water  with  the  addition  of  a 
little  sugar,  and  for  a  child  of  2-4  years  old,  '^\-'^\\  repeated 
in  an  hour  will  A'ery  often  lessen  restlessness  and  induce 
drowsiness  if  not  sleep.  Between  the  ages  of  4  and  6  years,. 
the  dose  should  be  doubled,  and  between  6  and  10  trebled. 
From  10  to  14  years  of  age  the  dose  should  be  from  3^1  Siss? 
while  to  adolescents  and  adults  5!  -  jiiss  may  be  given,  and 
repeated  at  least  once  before  being  abandoned.  In  some 
cases  it  is  extraordinary^  how  rapidly  the  restlessness  ceases 
as  the  patient  comes  under  the  infiuence  of  the  drug,  but  in 
others  it  may  be  necessary  to  proceed  with  chloral  after  two 
or,  at  most,  three  doses  of  whiskv  have  been  taken. 


Scarlet  Fever.  241 

In  using  chloral  us  uii  liypnotic  in  sleepless  and  restless 
cases  of  the  f^raver  types  of!  scarlet  fever,  except  wluni  th(; 
usual  occasional  dose  is  employed,  the  jjersoual  attention  of 
the  physician  is  necessary.  The  administration  of  the  drug 
must  not  be  left  to  the  patient's  personal  attendant,  even 
when  this  happens  to  be  a  nurse  of  considerable  experience,  as 
the  treatment  is  not  wholly  devoid  of  risk  on  account  of  the 
large  doses  which  may  have  to  be  given.  The  risk,  however, 
must  be  run  in  cases  of  this  type,  as  unless  the  patient  is 
made  to  sleep  and  to  sleep  quickly,  the  case  will  end  fatally, 
but  as  such  a  risk  can  only  be  run  by  a  medical  man,  the 
23liysician  must  take  the  burden  upon  himself  personally. 

The  dose  of  chloral  must  be  regulated  according  to  the  age  of 
the  patient.  For  a  child  of  two  to  four  years  of  age,  2\  grains 
of  the  hydrate  should  be  given  in  a  little  water,  while  for  an 
iidult  a  full  dose  of  30  grains  must  be  used,  and  intermediate 
ages  should  have  a  dose  proportionate  to  the  age.  The  dose 
ought  to  be  repeated  every  hour  until  drowsiness  is  produced, 
taking  care  that  the  administration  of  the  drug  stops  short 
of  poisoning.  Careful  observations  must  be  taken  of  the 
temperature  and  pulse,  as  any  considerable  fall  of  tempera- 
ture or  weakness  of  pulse  are  indications  that  the  drug  has 
been  pushed  to  the  verge  of  toleration,  and  its  use  must  be 
■discontinued  and  a  rectal  injection  of  hot  coffee  given  to 
guard  against  collapse.  It  is  extraordinar}^,  however,  how 
well  chloral  is  borne  by  those  restless  cases  who  present 
evidence  of  profound  toxaemia,  and  the  fear  of  chloral  on  the 
part  of  the  physician  is  as  dangerous  for  the  patient  as  the 
possibility  of  overdose.  The  early  recognition  of  the  kind  of 
case  in  which  chloral  is  likely  to  be  of  service  is  often  of  great 
importance;  it  ought  always  to  be  used  when  in  severe  cases 
there  is  much  restlessness  and  vigilant  delirium,  and  should 
be  given  as  soon  as  possible  after  these  sA^mptoms  have  been 
observed. 

If  the  throat  is  painful,  relief  may  be  obtained  by 
spraying  the  fauces  with  a  solution  of  carbolic  acid,  1-60,  and 
I)y  applying  hot  fomentations  or  tepid  compresses  to  the  neck. 

In  the  presuppurative  stages  of  cervical  adenitis  hot 
moist  dressings  of  cotton-wool  soaked  in  a  solution  of  carbolic 


242  Chapter  XV. 

acid  1-60,  are  usually  suiRcieiit  to  relieve  pain,  indeed,  in  mild 
cases  it  is  often  sufficient  to  wrap  the  neck  in  warm  cotton- 
wool. The  glycerine  of  belladonna  applied  on  a  hot  compress 
will  frequently  bring  relief  when  the  carbolic  dressings  have 
failed.  It  is  not  wise  to  use  linseed  poultices,  as  such  appli- 
cations encourage  suppuration  which  may  in  many  cases  be 
prevented  if  other  methods  of  treatment  are  adopted. 

On  the  occurrence  of  suppuration  the  abscess  must  be 
opened  and  treated  on  proper  surgical  lines. 

Rhinitis  is  best  treated  by  frequent  washing  out  of  the 
nose  with  a  saturated  solution  of  boric  acid  or  a  mixture  of 
glycothymolin  and  distilled  water  of  a  strength  of  1  to  5.  If 
there  is  much  excoriation  of  the  edge  of  the  nostrils,  it  may 
be  necessary  to  apply  nitrate  of  silver  or  pure  carbolic  acid  to 
the  sores  to  accelerate  their  healing. 

Otorrhea  is  best  treated  by  washing  out  the  ear  with  a 
saturated  solution  of  boric  acid  thrice  daily,  carefully  drying 
the  cavity  with  sterile  wool  after  syringing,  and  insufflating 
some  powdered  boric  acid  when  the  cavity  is  quite  dry.  Suit- 
able solutions  of  Izal  or  Cook's  "  Co-fectant  "  are  sometimes 
effective  when  boric  acid  fails. 

In  those  cases  where  there  is  pain  in  the  ear  before  the 
occurrence  of  purulent  discharge,  the  treatment  instituted  by 
A.  A.  Gray  is  often  of  service.  It  consists  in  introducing  a 
few  drops  of  anilin  combined  with  cocaine  and  carbolic  acid 
into  the  ear,  and  it  is  extraordinary  how  frequently  this 
method  of  treatment  will  relieve  pain  and  prevent  suppura- 
tion. In  certain  cases  of  severe  earache  at  the  beginning  of 
an  otitis  media  when  ordinary  anodyne  applications  and 
"Gray's  Mixture"  have  afforded  no  relief,  it  may  be  neces- 
sary to  puncture  the  tympanic  membrane  to  relieA^e  the  ten- 
sion in  the  ear.  The  pain  of  earache  is  so  intolerable  that  no 
efforts  should  be  spared  for  its  relief,  and  a  patient  should 
be  allowed  to  suffer  as  little  as  possible. 

Abscess  in  the  mastoid  region  demands  incision  to  the 
bone,  and  if  there  is  no  evidence  of  disease  in  the  mastoid 
cells  this  is  all  that  is  required.  If,  however,  there  is  evi- 
dence of  disease  in  the  bone,  it  will  be  necessary  to  clear  out 
the  antrum  and  cells,   but  this  operation  is  very  rarely  necessary 


Scarlet  Fever.  243 

during  the  time  that  a  patient  is  under  treatment  for 
scarlet  fever,  and  should,  if  possible,  be  delayed  until  he  i;* 
free  of  infection. 

A  post-pharyngeal  abscess  must  l)e  opened  with  due  pre- 
cautions as  soon  as  it  is  diagnosed. 

"Collar-neck"  and  cervical  cellulitis  also  demand  surgical 
interference.  In  a  simple  cellulitis  it  is  usually  best,  })efore 
making  an  incision,  to  apply  large  moist  dressings  of  a  1-60 
carbolic  solution  until  it  is  evident  at  what  point  sloughing 
will  occur.  On  the  occurrence  of  a  "collar-neck,"  however, 
an  incision  should  be  made  without  delay  along  the  line 
of  the  sterno-mastoid  muscle,  as  it  frequently  happens  that 
a  little  pus  will  be  obtained  deep  in  the  neck  behind  the 
sternal  attachment  of  the  muscle,  and  in  dealing  with  this 
condition  this  region  should  always  be  explored  and  drained. 
If,  as  is  usual,  the  condition  is  due  to  an  infection  by  a  strep- 
tococcus which  is  commonly  obtained  in  pure  culture,  20-40 
c.c.  of  a  polyvalent  antistreptococcal  serum  should  be  injected 
subcutaneously  as  soon  as  possible,  and  20  c.c.  repeated  at  in- 
tervals of  twelve  hours  until  three  or  four  doses  have  been 
given. 

Suppurative  arthritis  must  be  treated  by  free  incision  as 
soon  as  periarticular  redness  and  oedema  make  their  appear- 
ance, and  in  some  cases  free  incisions  on  either  side  of  the 
joint  seem  to  prevent  the  formation  of  pus  in  the  joint  itself. 
If  there  be  pus  in  a  joint  the  cavity  must  be  opened  and 
drained. 

In  scarlatinal  arthritis  and  myalgia,  treatment  is  directed 
towards  the  securing  of  free  elimination  and  the  relief  of 
pain.  My  own  experience  is  that  the  salicylates  internally 
exercise  no  specific  influence  on  the  pain  or  the  cause  of  the 
attack  as  in  acute  rheumatic  fever,  and  I  have  ceased  to  employ 
them  in  this  way.  I  have  found,  however,  that  the  use  of 
an  ointment  consisting  of  methyl  salicjdate  3iii  and  lanolin 
§ii  applied  on  lint  and  covered  with  guttapercha  tissue  will 
often  relieve  joint  pains  and  myalgia.  Sometimes  it  is  suffi- 
cient to  wrap  the  joints  in  cotton- wool,  with  or  without  a 
covering  of  gutta-percha  tissue,  and,  when  other  means  fail, 
the  application  of  the  glycerine  of  belladonna  3i  or  5ii  o^^ 


244  Chapter  XV. 

a  hot  fomentation,  frequently  gives  relief  from  pain.  After 
the  more  acute  stage  of  the  arthritis  has  passed  off  massage  of 
the  affected  joint  and  limbs  should  be  employed. 

Elimination  should  be  encouraged  by  the  free  use  of  the 
•citrates  of  soda  and  potash  and  by  the  employment  of  mer- 
curial purgatives,  calomel,  blue  pill  or  gray  powder,  and  the 
.aperient  sulphates. 

The  presence  of  even  a  slight  arthritis  or  myalgia  is  an 
indication  for  keeping  the  patient  strictly  in  bed  until  the 
attack  has  completely  passed  off.  If  the  patient  is  thus  kept 
strictly  at  rest  and  his  eliminative  functions  stimulated  as 
suggested,  the  risk  of  the  occurrence  of  endocarditis  and  other 
troubles  of  "  rheumatic  "  origin  will  be  greatly  lessened. 

Pleurisy  and  jaundice  are  treated  on  ordinary  lines. 

Vomiting  is  best  treated  by  strict  dieting  and  the  exhi- 
'bition  of  small  quantities  of  iced  champagne.  When  it 
occurs  in  profoundly  toxic  cases  rectal  or  intracellular  injec- 
tions of  normal  saline  solution  at  a  suitable  temperature  will 
:sometimes  control  it. 

Diarrhoea  indicates  the  necessity  for  careful  diet,  and 
Dover's  powder  combined  with  grey  powder  or  calomel  will 
be  found  to  be  of  service.  As  in  enteric  fever,  the  lower 
bowel  should  be  irrigated  daily  with  warm  water,  and  the 
use  of  a  starch  or  starch  and  opium  enema  will  frequently 
■bring  relief. 

Acute  nephritis  calls  for  the  greatest  possible  care  on  the 
part  of  the  physician.  In  an  ordinary  case,  where  there  is 
no  suppression  of  urine,  although  the  output  may  be  scanty, 
when  there  is  little  anasarca  or  ascites,  and  the  ursemic  symp- 
toms are  not  urgent,  it  is  sufficient  to  keep  the  patient  very 
strictly  in  bed  and  free  from  the  risk  of  surface  chill,  to  in- 
sist on  his  taking  a  purely  fluid  dietary  in  large  quantity, 
and  to  administer  alkaline  diuretics  in  the  form  of  the  diure- 
iic  salts  of  potash  or  "  Imperial  Drink."  It  is  often  a  matter 
of  great  difficulty  to  persuade  a  child  to  drink  suJ0B.ciently 
during  an  attack  of  scarlatinal  nephritis,  and  I  have  found 
ihe  creation  of  an  artificial  thirst  by  painting  the  child's 
mouth  and  tongue  with  a  saturated  solution  of  sodium 
chloride  to  answer  very  well  in  some  cases. 


Scarlet  Fever.  245 

Suppression  of  urine  may  be  treated  by  dry-cupping  or 
wet-cupping  over  the  loins,  by  bleeding  followed  by  the  intra- 
venous or  intracellular  injection  of  a  pint  or  more  of  normal- 
saline  solution,  or  by  hot  wet  packs. 

If  ur£emic  symptoms  are  present,  even  if  only  to  the 
extent  of  headache  and  nausea,  hot  wet  packs  should  be  used, 
and  if  this  is  of  no  avail  resort  may  be  had  to  the  steam  bath, 
to  wet-cupping  over  the  loins,  or  to  bleeding  from  a  vein 
followed  by  saline  transfusion. 

Free  movement  of  the  bowels  is  an  essential  part  of 
treatment,  and  the  use  of  the  aperient  sulphates  in  fairly  large 
doses  is  to  be  recommended.  Not  only  is  it  necessary  to 
stimulate  peristalsis,  but  it  is  wise  to  use  aperients  which 
determine  a  loss  of  fluid  by  the  bowel,  so  that  the  deficiency 
in  urinary  excretion  may  be  thus  compensated  for  to  some 
extent. 

After  all  blood  has  disappeared  from  the  urine,  which 
may  be  after  a  few  days  or  not  until  some  weeks  have  elapsed, 
if  it  be  found  that  albumin  continues  to  be  present  in  the 
urine  for  more  than  a  week  or  so,  the  use  of  iron  is  often 
found  to  be  followed  by  good  results.  Under  these  circum- 
stances, no  better  preparation  exists  than  the  old-fashioned 
tincture  of  the  perchloride  of  iron,  which  should  be  given  three 
or  four  times  a  day  after  food,  in  doses  of  from  5-15  minims 
according  to  the  age  and  tolerance  of  the  patient. 
Some  few  patients  may  show  a  gastric  intolerance  of  iron  in 
this  form,  and  with  these  the  scale  of  preparations  may  be 
used  or  a  mixture  of  the  perchloride  of  iron  and  the  liquor  of 
the  Acetate  of  Ammonia,  which  is  a  way  of  giving  the  fresh 
acetate  of  iron  combined  with  a  diaphoretic. 

Absolute  rest  in  bed  until  the  urine  is  free  from 
albumin,  or  until  some  weeks  at  least  have  elapsed  after  the 
disappearance  of  blood  is  absolutely  essential.  It  must  be 
remembered,  however,  that  in  certain  cases,  where  a  trace  of 
albumin  has  persisted  in  the  urine  for  many  weeks  in  spite  of 
rigid  keeping  in  bed  and  suitable  diet  and  drug  treatment, 
the  albumin  disappears  after  the  patient  has  been  allowed  up 
for  a  few  days.  If  there  is  much  albumin  in  the  urine  the 
patient  should  not  be  allowed  to  get  up  unless  the  case  has, 


246  Chapter  XV. 

in  the  opinion  of  the  physician,  become  chronic,  and  there- 
fore quite  incurable.  In  such  cases,  reasonable  freedom  must 
be  given  to  the  patient,  or  he  will  soon  lose  in  general  condi- 
tion more  than  he  can  gain  in  respect  of  the  local  lesion. 

One  cannot  urge  too  stronglj^  the  necessity  for  rest  and 
protection  from  surface  chill  during  the  progress  of  a  scar- 
latinal nephritis,  and  it  is  far  better  to  err  on  the  vside  of 
over-caution  than  of  rashness  in  the  conduct  of  such  cases. 
The  whole  future  of  a  patient  may  be  ruined  through  the 
physician  yielding  to  the  importunities  of  ignorant  and  im- 
patient relatives  who  resent  the  prolonged  medical  attendance 
and  the  confinement  of  the  patient  to  bed  who  seems  fairly 
well. 

When  it  is  remembered  that  the  only  way  to  rest  a  kidney 
is  to  lessen  nitrogenous  tissue  waste,  to  avoid  congestion  o£ 
the  organ,  and  give  a  minimum  amount  of  nitrogenous  food, 
the  necessity  for  strict  confinement  to  bed  becomes  very  plain. 

Attention  to  the  function  of  the  skin  is  very  necessary, 
and  sponging  with  hot  water  in  which  some  mustard  has 
been  mixed  is  very  useful.  The  sponging  must  be  done  piece- 
meal, and  the  greatest  care  must  be  taken  during  the  process 
to  avoid  any  risk  of  chill.  The  bed  must  be  so  placed  as  to 
be  out  of  any  draught,  although,  as  in  all  cases  of  fever,  the 
room  must  be  kept  fresh  and  well-ventilated. 

The  use  of  digitalis  as  a  diuretic  in  acute  scarlatinal 
nephritis  is  not  to  be  recommended,  as  it  tends  to  aggravate 
the  nausea  which  is  so  frequently  present.  The  alkaline 
diuretics,  hot-packing,  the  application  of  hot  linseed  poul- 
tices to  the  loins  and  the  use  of  the  wet  or  dry  cups  are 
infinitely  preferable,  and  much  more  effective. 

Pilocarpine  may  be  used  in  certain  cases  where  other 
means  fail  to  induce  sweating  and  increased  urination,  but 
the  toxic  effects  of  the  drug  are  easily  produced,  and  it  is 
not  advisable  to  push  it  when  the  patient  is  very  young  or  of 
poor  stamina. 

Diet. —  The  diet  during  the  febrile  period  of  scarlatina 
must  be  fluid,  and  should  consist  mainly  of  milk,  diluted  -with 
barley  water,  plain  warm  water,  or  some  alkaline  aerated 
water,  with  the  addition  of  a  little  citrate  of  soda,  say  three 


Scarlet  Fever.  •J47 

grains  to  the  ounce.  Tlie  addition  of  ice  to  tlie  milk  m  often 
very  pleasant  to  tlie  patient,  whose  mouth  is  hot  and  whose 
throat  is  painful,  and  water  may  be  given  in  small  quantities, 
as  often  as  is  asked  for.  A  little  chicken  tea  may  be  given 
once  or  twice  in  the  day,  either  hot  or  cold,  according  to 
the  fancy  of  the  patient. 

After  the  fever  has  subsided,  solids  should  be  added,  but 
only  in  the  shape  of  carbohydrate  foods,  so  that  rusks,  toast 
and  bread,  with  butter,  milk  puddings,  whatever  fruit  is 
available,  either  raw  or  cooked,  rice,  potatoes,  green  vege- 
tables, preparations  of  oatmeal  and  maccaroni  or  spaghetti 
should  form  the  dietary  of  the  convalescent,  besides  as  much 
milk  as  he  can  take  with  comfort,  for  at  least  ten  days  after 
complete  defervescence  has  occurred.  Should  the  patient's 
appetite  demand  it,  fish  may  then  be  added,  but  it  is  well  to 
withhold  eggs,  soup,  poultry  and  butcher-meat  until  the  time 
has  passed  during  which  nephritis  usually  occurs. 

The  addition  of  butter  after  cooking  the  rice,  potatoes, 
green  vegetables  and  maccaroni  makes  them  much  more 
palatable. 

In  acute  nephritis  the  diet  should  consist  entirely  of 
milk,  water,  and  diuretic  drinks  until  at  least  a  week  after 
all  blood  has  been  found  to  be  absent  from  the  urine  after 
careful  testing  and  microscopical  examination,  and  the  out- 
put of  urine  has  risen  above  the  normal.  A  carbohydrate 
dietary  such  as  indicated  above  may  be  then  cautiously  in- 
stituted, but  the  amount  should  at  first  be  very  limited.  The 
patient  ought  to  be  kept  entirely  on  this  carbohydrate  diet, 
which  is  ample  and  capable  of  quite  interesting  variation, 
until  such  time  as  the  albumin  has  entirely  disappeared  or  the 
disease  is  seen  to  have  become  definitely  chronic. 

Epidemiology. —  Scarlet  fever,  like  the  poor,  is  always  with 
us,  but  is  liable  to  great  seasonal  variations.  Epidemic  in- 
crease usually  occurs  in  the  late  spring  or  early  summer,  and 
to  a  lesser  degree  in  autumn.  It  may  be  conveyed  by  direct 
contact  or  by  infected  materials,  and  it  seems  likely  that  the 
infecting  agent  of  scarlet  fever  may  retain  its  virulence  for  a 
long  time  outside  the  body,  so  that  clothes,  books,  letters, 
toys  and  other  articles  which  had  been  in  contact    with    a 

s  2 


248  Chapter  XV. 

sufferer  from  scarlet  fever  and  liad  been  put  away  for  months, 
have,  apparently,  on  being  brought  out  again,  given 
rise  to  a  fresh  outbreak  of  the  disorder.  It  is  also 
capable  of  being  conveyed  from  one  to  another  through 
the  medium  of  a  third  person  who  is  not  suffering 
from  the  disease,  and  all  persons  who  are  in  contact  with 
scarlet  fever  ought  to  remember  that,  without  scrupulous  care, 
they  may  themselves  act  as  foci  for  the  further  spread  of  the 
infection. 

An  epidemic  of  scarlet  fever  frequently  originates  in  con- 
nection with  a  milk-supply,  but  it  is  very  doubtful  if  the 
disease  is  conveyed  from  the  cow  to  the  milk.  In  most  cases 
it  is  found  that  a  farm-servant  or  attendant  at  the  dairy  has 
been  suffering  from  a  mild  and  unrecognised  form  of  the 
disease,  and  has  infected  the  milk  which  he  or  she  has 
handled. 

The  nasal  and  buccal  discharges  are  infective  from  the 
first  moment  of  onset  of  the  disease,  and  continue  to  be  so 
for  at  least  six  weeks  afterwards.  Infection  can  also  be  con- 
veyed by  the  desquamated  skin,  especially  during  the  early 
stages  of  the  process  of  desquamation.  It  is  extremely  un- 
likely that  a  secondary  desquamation  is  infectious,  except  in 
so  far  as  the  particles  of  skin  may  serve  as  a  resting  place  and 
means  of  conveyance  for  the  infective  dust  of  a  ward  in  which 
many  scarlet  fever  cases  are  under  treatment. 

If  there  is  any  excoriation  or  ulcer  on  the  nasal  or  buccal 
mucous  membrane,  on  the  tonsil  or  at  the  angle  of  the  mouth 
or  edge  of  the  nostril,  the  nasal  and  buccal  discharges  may  be 
virulently  infective  until  these  breaches  of  surface  are  thor- 
oughly healed,  although  two  or  three  months  may  have 
elapsed  since  the  onset  of  the  fever,  and  the  recognition  of 
this  fact  is  of  the  greatest  importance  both  in  the  adminis- 
tration of  fever  hospitals  and  in  the  management  of  cases  at 
home. 

It  is  the  usual  custom  to  isolate  all  cases  of  scarlet  fever 
until  all  traces  of  primary  desquamation  are  gone,  which 
means  for  six  to  eight  weeks,  but  to  isolate  for  longer  periods 
those  patients  who  have  any  breach  of  surface  on  the  mucous 


Scarlet  Fever.  240 

membrane  of  the  nose  or  mouth  or  on  the  skin  about  the 
nose  or  mouth,  or  who  have  any  unhealed  wound  wliich  has 
resulted  from  a  "  septic  "  combination  of  scarlet  fever — to 
isolate  such  cases,  in  fact,  until  mucous  membrane  and  skin 
are  absolutely  healthy  as  far  as  can  be  seen  after  careful  ob- 
servation. There  is  little  doubt  that  a  slight  rhinitis  with 
excoriation  about  the  nostrils  may  be  answerable  for  tlie 
infecting  of  far  more  cases  than  an  incomplete  primary 
desquamation . 

Death-rate. — The  death-rate  of  scarlet  fever  is  at  the 
present  day  very  low.  It  is  probable  that  in  a  good  class 
practice  it  will  not  often  exceed  2  per  cent.,  and  even  in 
Hospital  the  death-rate  varies  between  2  . 5  and  6  per  cent. 
The  mortality  rate  is  much  higher  in  children  between  the 
ages  of  one  and  five  years  than  in  those  who  are  attacked 
earlier  or  later  in  life.  Scarlatina  is,  indeed,  very  rare 
among  infants,  especially  when  at  the  breast. 

Second  attacks. — These  are,  considering  the  yearly  in- 
cidence of  scarlet  fever,  comparatively  uncommon,  but  they 
are  quite  frequently  met  with.  More  than  two  attacks  are  very 
rarely  seen.  The  second  attack  may  occur  before  the  patient  is 
thoroughly  convalescent  from  a  first  attack,  or  at  any  time 
after  the  first  attack  has  terminated,  although  it  is,  perhaps, 
more  common  to  find  that  the  second  attack  occurs  either 
within  two  years  of  the  first,  or  after  many  years  have 
elapsed. 

Home  Prophylaxis. —  In  every  instance  where  the  accom- 
modation is  not  sufficient  to  ensure  the  complete  isolation  of 
the  patient  and  his  attendant  from  the  life  of  the  household, 
he  should  be  sent  to  hospital,  as  otherwise  his  family,  even 
though  they  are  not  themselves  the  subjects  of  scarlet 
fever,  may  act  as  carriers  of  the  contagion  from  the  patient 
to  others. 

Where,  however,  the  accommodation  of  the  house  permits 
the  reserving  of  a  suite  of  rooms  or  entire  floor  for  the  use  of 
the  patient  and  his  attendant,  he  may  be  kept  at  home,  and, 
if  strictly  isolated,  need  not  convey  the  infection  to  others. 

The  attendant  must  have  a  special  overall  and  dress  for 
use  in  the  sickroom  and  ought  to  change  her  clothes  entirely 


250  Chapter  XV. 

and  take  a  bath  before  going  out.  The  sick-room  should  be 
stripped  of  pictures,  hangings,  stuifed  furniture  and  carpet,' 
and  the  floor  ought  to  be  washed  daily  with  some  suitable  dis- 
infectant such  as  '' Sanitas  "  or  Cook's  "  Co-f ectant "  fluid. 
Anything  which  has  been  in  contact  with  the  patient,  such  as 
bed-clothes,  furniture,  or  table-utensils,  even  during  the  first 
few  hours  of  illness,  must  be  carefully  disinfected  before  other 
members  of  the  household  are  exposed  to  contact  with  fhem.  As 
desquamation  commences,  ib  is  advisable  to  rub  the  skin  with 
a  little  oil,  to  prevent  as  far  as  possible  the  dissemination  of 
infective  particles  of  skin  throughout  the  house.  All  body 
linen  and  bed-clothes  must  be  steeped  in  a  solution  of  car- 
bolic acid,  "  Co-fectant "  or  formalin  for  some  hours  before 
being  sent  to  the  wash,  and  all  table  utensils  must  be  im- 
mersed in  boiling  water  before  being  allowed  to  leave  the 
sick-room.  The  urine  and  stools  should  be  mixed  with  at 
least  a  third  of  their  bulk  of  "  Co-fectant "  or  crude  car- 
bolic preparation  before  being  allowed  to  pass  into  the  drains. 

At  the  end  of  the  fourth  week  of  the  disease  or  some 
three  weeks  after  the  temperature  has  finally  fallen  to  nor- 
mal, the  patient  should  have  a  hot  bath  and  a  thorough 
scrubbing  with  soap,  every  second  evening.  This  process 
hastens  desquamation,  and  renders  the  desquamating  skin  less 
infective.  When  nephritis  has  occurred,  the  bath  should  not 
be  given  until  the  urine  has  been  free  from  albumin  for  a  few 
days,  or  until,  for  the  reasons  stated  above,  the  patient  is 
allowed  to  get  up  even  though  there  is  still  some  albumin  in 
the  urine.  It  is  well  to  arrange,  if  at  all  possible,  that  a 
patient  does  not  mix  with  other  children  for  at  least  a  week 
after  he  is  going  about  and  all  infection  is  supposed  to  be 
gone. 

Public  Health  Administration. — On  the  notification  of  a  case 
of  scarlet  fever,  the  house  in  which  it  has  occurred  ought  to 
be  inspected  and  advice  given  as  to  the  proper  isolation  of 
the  patient.  When  proper  isolation  is  not  possible,  the 
case  should  be  removed  to  hospital  at  once.  At  the  end  of 
the  case  or  on  the  removal  of  the  patient  to  hospital  the 
rooms  in  which  the  patient  has  been  at  any  time  during  his 
illness  must  be  thoroughly  disinfected.       Wallpaper   should 


Scarlet  Fever.  251 

be  stripped  and  the  walls,  floors,  ceiling,  bed  and  wood-work 
washed  down  with  a  solution  of  formalin,  and  the  room  there- 
after thoroughly  aired  for  some  days.  Bedding  and  any 
clothing  or  other  articles  capable  of  proper  disinfection  which 
have  been  in  the  room  during  the  patient's  illness  must  be 
dealt  with  by  steam  or  formalin,  according  to  their  texture. 
Books  and  papers  used  by  the  patient  ought  to  be  destroyed, 
although  it  is  possible  to  treat  valuable  books  witli  formalin 
vapour,  and  exposure  to  fresh  air,  with  a  considerable  degree 
of  efficiency. 

The  milk-supply  of  the  household  should  be  strictly  in- 
vestigated and  inspection  made  of  all  employees  engaged 
either  at  the  farm  or  milk-shop  in  case  any  of  them  has 
been  suffering  from  an  unrecognised  attack  of  scarlet  fever. 

When  there  seems  to  be  any  likelihood  that  an  epidemic 
has  arisen  in  connection  with  an  institution  or  a  school,  the 
inmates,  pupils  and  employees  should  be  carefully  examined, 
and  the  condition  of  their  health  during  the  previous  six  or 
eight  Aveeks  investigated,  lest  any  of  them  may  have  a  mild, 
unrecognised  case  of  the  disease,  and  may  be  acting  as  infec- 
tive foci  for  their  associates. 

The  condition  of  the  throat,  tongue  and  skin  should  be 
carefully  noted,  and  special  enquiries  made  of  the  persons 
under  suspicion,  parents  and  associates  as  to  the  occurrence  of 
any  febrile  complaint  associated  with  rash,  sore  throat  or 
desquamation,  and  doubtful  cases  should  be  isolated  for 
observation. 

As  in  enteric  fever,  the  staff  of  the  health-office  should 
be  placed  at  the  disposal  of  practitioners  in  the  district  for 
consultation  in  doubtful  cases. 


(   252  ) 


Chapter  XVI. 

MEASLES. 

Synonyms. — Morbilli,  Rubeola. 
French  :    La  Rougeole. 
German  :  Die  Masern. 

Definition. —  An  acute  infectious  specific  fever,  having  a 
sudden  onset,  a  catarrhal  or  pre-eruptive  stage  and  a  charac- 
teristic eruption. 

Incubation  Period. — The  incubation  period  of  measles  is 
much  longer  than  that  of  scarlet  fever,  varying,  according 
to  different  authors,  between  five  and  fourteen  days.  By 
far  the  most  common  period  of  incubation  is  between  eight 
and  ten  days,  and  the  exceptions  to  this  are  very  few. 

Rash. — The  rash  appears  as  a  general  rule  between  the 
third  and  fourth  daj^  of  illness,  but  in  some  cases  its  appear- 
ance is  delayed  until  the  fifth  day.  It  first  makes  its  appear- 
ance below  and  behind  the  ears  and  on  the  forehead, 
particularly  at  the  edge  of  the  hair,  and  quickly  spreads  to 
the  face,  trunk,  arms  and  legs.  It  remains  bright  and  dis- 
tinct for  from  twenty-four  to  forty-eight  hours  and  then  begins 
to  fade,  following  the  same  sequence  as  on  its  appearance,  so 
that  while  it  may  have  practically  faded  on  the  face  it  may 
still  be  bright  on  the  legs  and  thighs.  After  fading,  it  almost 
always  leaves  a  certain  amount  of  brownish-red  staining 
behind  it. 

The  eruption  consists  of  papules,  distinctly  raised  above 
the  level  of  the  skin.  These  papules  tend  to  occur  in  crescentic 
or  almost  circular  groups,  surrounding  a  central  area  of  white 
skin,  but  as  the  eruption  develops  the  concentric  areas  coalesce 
in  parts,  producing  large  irregular  blotches,  with  "scalloped  " 


Measles.  263: 

edges.  On  the  face,  neck  and  chest,  the  crescentic  patches 
may  be  so  closely  set  as  to  produce  a  more  or  less  xiniforni  red- 
ness, but  the  fact  that  the  eruption  is  definitely  raised  above- 
the  skin  serves  to  distinguish  it,  in  most  cases,  from  the  rash 
of  scarlet  fever.  The  fully  developed  eruption  is  fixed  and 
does  not  disappear  on  pressure. 

While  the  rash  on  the  skin  does  not  appear  until  the  third 
or  fourth  day,  it  is  apparent  on  the  soft  palate,  as  a  dusky 
mottling  associated  with  some  swelling  of  the  mucous  mem- 
brane, some  twelve  to  twenty-four  hours  earlier. 

Prodromal  Rashes  are  frequently  seen,  the  more  common 
being  a  brownish-red  subcuticular  mottling  like  a  shadow 
of  the  true  eruption,  which  may  be  very  apparent  on  the 
face,  neck  and  chest,  and  which  precedes  the  true  eruption 
by  about  twenty-four  hours  or  even  a  little  longer.  Scarlat- 
iniform  and  urticarial  rashes  have  also  been  observed. 

"  Koplik's  Spots,''  called  after  Koplik,  of  New  York^ 
who  first  described  them  fully,  are  small  bluish-white  spots 
surrounded  by  a  red  areola,  the  spot  and  areola  occupying  a 
space  not  much  larger  than  the  head  of  an  ordinary  pin.  They 
are  found  on  the  buccal  mucous  membrane,  first  making  their 
appearance  about  the  level  of  the  first  molar  tooth.  They  are 
few  in  number  in  the  early  hours  of  their  appearance,  and  may 
remain  few,  but  in  many  instances  they  become  very  numerous 
and  may  be  seen  not  only  on  the  mucous  membrane  of  the  cheeks 
but  also  on  the  mucous  membrane  on  the  inner  side  of  the  lips. 
As  they  develop,  the  distinctive  areola  is  lost  and  the  mucous 
membrane  in  this  neighbourhood  becomes  deeply  congested. 
The  spots  appear,  as  a  rule,  with  the  onset  of  the  first 
symptoms  of  measles,  and  precede  the  cutaneous  eruption  by 
some  two  or  three  days.  In  some  cases  they  appear  even  be- 
fore the  temperature  is  raised  above  normal.  They  are  not 
found  in  all  cases  of  measles,  but  are  present  in  the  majority 
of  cases,  and,  when  present,  are  of  the  greatest  diagnostic 
value.  They  are  not  found  on  the  palate,  and  fade  as  the 
cutaneous  eruption  appears. 

Desquamation  of  a  fine  branny  kind  usually  occurs 
on  the  face,  neck  and  trunk  after  the  rash  has  faded,  and  is 
sometimes  very  profuse. 


254  Chapter  XVI. 

Clinical  Types. — The  symptoms  of  onset  of  measles  are 
those  of  a  severe  nasal  and  pharyngeal  catarrh.  The 
patient  complains  of  fulness  in  the  frontal  region  and  fre- 
quently suifers  from  headache.  The  eyes  are  suffused  and 
blood-shot  and  there  is  acute  coryza.  A  certain  amount  of 
photophobia  is  always  present.  Cough,  of  a  curious  hard  dry 
variety  is  a  usual  symptom,  and  the  mouth  and  throat  feel  dry 
and  burning.  Hoarseness  is  frequently  present,  and  in  some 
cases  the  cough  has  a  definitely  laryngeal  character  from  the 
commencement.  A  few  coarse  rhonchi  are  often  audible  over 
the  chest.  The  temperature  may  be  little  raised,  or  may  be 
found  to  be  very  high  from  the  first  onset  of  symptoms,  or 
may  slowly  rise  as  the  attack  progresses.  The  catarrhal 
symptoms  persist  without  any  appearance  of  rash  save  Koplik's 
spots  or  the  prodromal  mottling  described  above  until  the  end 
of  the  second  or  third  day,  when,  in  addition  to  the  swelled 
and  reddened  condition  of  the  fauces,  a  mottled  appearance 
is  apparent  on  the  palate.  The  cutaneous  eruption  appears 
on  the  third,  fourth  or  fifth  day.  With  the  appearance  of 
the  rash,  the  behaviour  of  the  temperature  varies  in  different 
cases.  When  the  temperature  has  been  high  from  the  begin- 
ning of  the  illness, there  is  usually  a  distinct  drop,  perhaps  to 
normal,  just  before  the  eruption  begins  to  appear.  When  the 
fever  has  been  slight  from  the  onset  there  may  be  no  such 
drop,  and  in  those  cases  where  the  temperature  has  slowly 
risen  from  the  beginning,  no  remission  occurs  before  the 
appearance  of  the  rash. 

As  the  rash  appears,  the  catarrhal  symptoms  are  exagger- 
ated, and,  in  typical  cases,  the  patient  presents  a  very  charac- 
teristic appearance.  The  face  is  swollen  and  mottled  with  the 
eruption  ;  there  is  much  photophobia  and  the  eyelids  are 
swelled  and  reddened  ;  the  eyes  are  watery  and  there  is 
distinct  evidence  of  inflammation  of  the  conjunctivae.  Nasal 
discharge  is  profuse  and  watery,  the  fauces  are  reddened  and 
swelled  and  there  is  some  thin  exudate  present  on  the  tonsils, 
the  pillars  of  the  fauces  and  posterior  pharyngeal  wall.  The 
patient  coughs  and  sneezes  incessantly  and  looks  utterly  miser- 
able. A  little  bronchial  catarrh  is  the  rule  at  this  stage  of 
the  illness. 


Measles.  255 

Hoarseness  and  cough  of  a  laryngeal  character  may  be 
very  marked,  and,  indeed,  the  patient  may  suffer  from  an 
acute  laryngitis  with  all  tlie  signs  of  obstruction,  and  this 
condition,  associated  as  it  is  with  catarrh  of  the  bronchi, 
sometimes  very  considerable,  is  both  troublesome  and  dan- 
gerous. In  most  cases  the  catarrhal  symptoms  subside  with 
the  eruption  ;  the  ooryza  and  conjunctivitis  disappear,  the 
fauces  lose  their  swollen  appearance,  and  within  a  day  or  two 
of  the  disappearance  of  the  rash  all  traces  of  bronchial  catarrh 
are  gone.  The  nasal  and  conjunctival  discharges  often  become 
slightly  purulent  as  the  attack  passes  off,  and  in  the  morning 
the  nose  is  apt  to  be  stopped  up  Avith  inspissated  muco-pus, 
and  the  eyelids  tend  to  stick  together  during  sleep.  For  about 
a  week  after  the  disappearance  of  the  catarrhal 
symptoms  the  patient  is  languid  and  pale,  and  during  this 
stage  of  the  disease  demands  careful  attention.  Convalescence 
is  usually  complete  within  three  weeks  from  the  appearance 
of  tlie  rash  in  such  cases  as  are  only  moderately  severe  and 
have  presented  no  complications. 

Mild  types  of  measles  are  frequently  met  with  where 
the  initial  catarrhal  symptoms  are  quite  trifling  and  may  be 
expressed  by  a  slight  nasal  catarrh  without  fever,  and  in  these 
cases  the  rash  is  the  first  sign  Avhich  attracts  the  attention  of  the 
patient's  attendants.  '  The  rash  may  be  limited  entirely  to  the 
face,  neck  and  chest,  and  may  disappear  within  twenty-four 
hours.  In  such  cases  there  is  little  aggravation  of  the  catarrhal 
symptoms  with  the  appearance  of  the  rash,  although  even  in 
cases  so  mild  as  to  offer  considerable  difficulty  in  diagnosis 
a  little  bronchial  catarrh  is  common. 

Fuhninant  cases  sometimes  occur  in  which,  after  a 
catarrhal  stage  of  unusual  severity  during  which  the  patient 
is  greatly  prostrated,  the  rash  appears  but  may  not  develop 
fully,  being  evident  only  in  patches  on  the  face,  neck  and 
trunk,  and  having  a  definitely  hsemorrhagic  character  with 
abundant  petechia.  In  such  cases  death  occurs  from  simple 
toxsemia,  usually  about  the  second  or  third  day  after  the 
appearance  of  the  rash,  with  liyper-pyrexia,  well-marked 
nervous  symptoms  and  rapid  cardiac  failure. 


256  Chapter  XVI. 

In  other  cases  of  a  somewhat  fulminant  type,  the  rash 
appears  normally  after  a  severe  catarrhal  stage,  but  retires 
after  some  twelve  to  twenty-four  hours.  In  such  cases 
bronchial  catarrh  is  usually  a  marked  feature  of  the  disea^se, 
and  as  the  rash  retires  a  rapidly  advancing  broncho-pneu- 
monia may  develop,  or  the  patient  may  show  signs  of  cerebral 
disturbance  and  die  after  the  occurrence  of  convulsions  and 
coma. 

Cases  of  an  asthenic  type  are  sometimes  met  with, 
esj)ecially  in  infants,  when,  after  a  catarrhal  stage  which 
presents  no  unusual  features,  the  rash  develops  badly,  remain- 
ing faint  and  rather  bluish  in  colour,  and,  either  just  before 
the  temperature  falls  to  normal,  or  shortly  afterwards,  the 
pulse  becomes  rapid  and  irregular  and  the  patient  dies  from 
asthenia  and  cardiac  failure. 

Complications. — By  far  the  most  common  and  dan- 
gerous complication  of  measles  is  hronclio-pnemnonia.  It 
occurs,  as  a  rule,  just  as  the  eruption  appears,  or  a  little 
earlier,  but  is  sometimes  delayed  until  about  the  normal  time 
of  defervescence.  In  some  cases  the  condition  in  the  lung  is 
more  of  the  nature  of  a  capillary  hronchitis  than  a  true 
broncho-pneumonia,  and  on  examination  of  the  chest  fine 
moist  crepitations  are  audible  over  both  lungs  in  front  and 
behind.  In  such  cases  the  patient  suffers  from  a  sensation  of 
suffocation  and  commonly  shows  marked  cyanosis.  Some- 
times this  capillary  bronchitis  disappears  as  the  rash  fades, 
but  it  may  persist  after  the  fading  of  the  eruption,  indicating 
a  condition  of  great  gravity,  and  the  patient  may  die  with 
suffocative  symptoms  and  heart  failure  a  few  days  after  the 
occurrence  of  the  complication,  or  the  condition  may  persist  for 
weeks  and  patches  of  consolidation  may  appear  as  the  case 
progresses. 

The  usual  febrile  period  may  be  greatly  prolonged  b}^  the 
occurrence  of  broncho-pneumonia  or  capillary  bronchitis,  but 
in  many  cases  the  height  of  the  temperature  may  be  quite 
disproportionate  to  the  gravity  of  the  condition. 

Houghly  speaking,  broncho-pneumonia  and  capillary 
bronchitis  are   dangerous   in  proportion  to  the  youth   of  the 


Measles.  257 

patient,  bj  far  the  greatest  number  of  fatal  cases  occuiTing 
among  those  who  are  not  yet  old  enough  to  spit  and  blow  their 
noses.  Occasionally,  however,  among  adults,  bronclio-pneu- 
monia  may  be  dangerous  to  life,  especially  among  those  who 
have  recently  come  to  town  from  the  country  and  have  not  hud 
a  previous  attack  of  ^measles. 

Lobar  imeuvwnia  is  a  rare  occurrence,  but  is  sometimes 
met  with,  and  when  it  does  occur  is  not  uncommonly  associated 
with  a  pleural  effusion  which  may  become  purulent.  Recovery 
from  such  a  condition  is  usual,  but  convalescence  may  be 
greatly  protracted. 

Laryngitis  of  a  mild  type  is  so  common  both  in  the  pre- 
emptive and  eruptive  stages  of  measles  as  to  form  one  of  the 
symptoms  of  the  disease,  but  it  may  sometimes  be  so  severe  as 
to  warrant  a  special  mention  under  the  head  of  "  compli- 
cations." 

The  laryngitis  of  the  pre-eruptive  stage  may  come  on 
suddenly  and  give  rise  to  a  considerable  degree  of  laryngeal 
obstruction,  while  there  may  be  so  little  catarrh  of  the  nose, 
eyes,  and  bronchi,  that  the  true  nature  of  the  case  may  not 
be  at  all  apparent  until  the  eruption  appears. 

Again,  the  laryngitis  of  the  eruptive  stage  may  also  be 
severe  and  may  give  rise  to  such  a  degree  of  obstruction  that 
tracheotomy  may  have  to  be  performed.  Its  usual  association 
with  a  considerable  amount  of  bronchial  catarrh  at  this  period 
is  an  added  danger  for  tracheotomy,  which  should  not  be 
jjerformed  except  under  very  special  circumstances. 

While  the  laryngitis  of  the  eruptive  stage  is  usually  a 
simple  catarrhal  condition  like  that  of  the  pre-eruptive  stage,  it 
may  be  of  a  definitely  "  membranous  "  type,  with  thick  tena- 
cious exudate  about  the  cords,  not  similar  to  but  closely 
resembling  laryngeal  diphtheria.  This  condition  of  membran- 
ous larjaigitis  is  a  very  troublesome  and  dangerous  one,  and 
may  occur  after  the  rash  has  disappeared,  well  into  the  second 
week  of  the  disease. 

The  pre-eruptive  laryngitis  is  rarely  dangerous,  but  that 
which  appears  during  or  after  the  eruptive  period,  especially 
if  it  has  anything  of  a  membranous  character,  is  a  condition 


258  Chapev  XVI. 

of  some  gravity,  and  the  later  it  appears  in  the  course  of  the 
disease  the  more  dangerous  it  is. 

Cervical  adenitis  is  a  fairly  frequent  complication  in 
association  with  otitis  media,  and  often  goes  on  to  suppuration. 
It  does  not,  however,  occur  with  anything  like  the  same 
frequency  as  in  scarlet  fever. 

Otitis  Media  is  of  common  occurrence  and  ma}^  give  rise 
to  great  pain  in  the  ear.  In  many  cases,  however,  it  is 
comparatively  painless,  and  indeed  the  first  indication  of  its 
presence  may  be  a  purulent  discharge  from  the  meatus.  It  is 
frequently  accompanied  by  some  degree  of  cervical  adenitis. 
It  is  interesting  to  note  that  although  the  otitis  media  of 
measles  is  not  usually  so  acute  as  that  met  with  in  scarlet 
fever,  it  is  not  infrequently  followed  by  permanent  damage  to 
hearing,  and,  it  may  be,  by  complete  deafness. 

Affections  of  the  eye  are  of  common  occurrence,  and  con- 
stitute one  of  the  most  important  groups  of  the  complications 
of  measles. 

Some  conjunctivitis  is  almost  always  present,  with  a 
marked  degree  of  photophobia,  and  in  many  cases  it  is  very 
severe,  with  profuse  purulent  discharge  and  much  swelling  of 
the  eyelids. 

Corneal  ulcer  is  not  infrequently  met  with,  and  constitutes 
a  grave  danger  to  the  patient.  It  is  frequently  serpiginous  in 
character  and  associated  with  hypopyon. 

Panophthalmitis  sometimes  follows  on  the  occurrence  of 
an  ulcer  of  the  cornea;  indeed,  where  the  infecting  organism 
is  the  streptococcus,  the  eye  may  be  totally  destroyed  within  a 
few  hours  of  the  first  appearance  of  the  ulcer. 

Any  of  the  micro-organisms  associated  with  conjunctivitis 
and  corneal  ulcer  may  be  present  in  the  conjunctivitis  and 
corneal  ulcer  complicating  measles,  but  the  most  common  are 
the  ordinary  pyogenic  organisms,  the  streptococci,  the 
staphylococci  and  the  pneumococcus. 

It  is  extraordinary  how  virulent  and  severe  the  aifections 
of  the  eye  may  be  in  measles,  and  it  is  well  to  remember  that 
an  attack  of  conjunctivitis,  especially  in  a  child  whose  previous 
health  has  not  been  good,  may  speedily  lead  to  complete  loss 


Measles.  259 

of  sight  in  at  least  one  eye,  possibly  in  both,  and  to  treat  tlie 
affection  with  proportionate  car©  and  respect. 

The  conjunctivitis  of  measles  is  highly  infectious,  and 
where  several  children  are  being  nursed  in  the  same  room 
great  care  must  be  taken  to  avoid  infecting  the  eyes 
of  one  from  those  of  another,  and  doctors  and  nurses  attending 
such  cases  will  do  well  to  take  particular  care  to  avoid 
all  risk  of  infecting  their  own  eyes. 

Enteritis  may  occur  during  convalescence,  and  is  a  trouble- 
some and  often  dangerous  complication.  The  motions  are 
frequent  and  consist  largely  of  mucus  and  blood,  with  shreds 
of  mucous  membrane,  and  occasionally  large  mucous  casts. 
This  affection  is  more  apt  to  occur  in  children  who  have  had 
broncho-pneumonia  and  are  ill-nourished  and  feeble,  and  may 
persist  for  weeks  until  either  death  occurs  or  convalescence  is 
slowly  established. 

Stomatitis  is  not  uncommon  and  may  be  ulcerative  in 
character. 

Cancrum  oris  and  noTna  are  occasionally  seen  but  occur 
only  among  children  who  have  been  previously  ailing  and 
cachectic. 

A  purulent  vulvitis  and  vaginitis  is  not  uncommon  during 
the  stage  of  convalescence  and  desquamation,  and  is  a  highly 
contagious  disorder,  so  that  when  several  girl-children  are 
being  nursed  together  the  greatest  care  must  be  taken  to  avoid 
all  risk  of  infecting  one  from  another. 

Among  the  rare  complications  of  measles  may  be  included 
endocarditis  and  'pericarditis,  tetany,  peripheral  neuritis  and 
dissemfiinated  myelitis,  but  these  conditions  are  extremely  un- 
common and  merit  no  more  than  passing  mention. 

Nephritis  very  rarely  occurs. 

Measles  may  be  complicated  by  other  infectious  diseases, 
such  as  scarlet  fever  and  diphtheria,  and  where  such  compli- 
cations occur  the  outlook  for  the  patient  is  usually  grave.  An 
attack  of  measles  is  no  good  preparation  for  fighting  another 
infectious  fever  whose  manifestations  are  in  themselves  quite 
serious  enough. 


260  Chapter  XVI. 

Sequelae.— C/'/'o/iic  otitis  media,  with  its  well-known 
attendant  ills,  may  result  from  an  attack  of  acute  middle-ear 
suppuration   occurring   during  measles. 

Opacities  of  the  cornea  not  infrequently  follow  on  corneal 
ulcer. 

In  young  children  measles,  like  certain  other  of  the  acute 
ievers,  may  be  the  immediately  predisposing  cause  of  the 
•occurrence  of  acute  anterior  poliomyelitis,  with  resulting 
ii trophy  of  one  or  more  groups  of  muscles. 

Similarly,  it  is  not  unusual  to  find  that  rickets  may  follow 
■quickly  on  an  attack  of  measles. 

In  both  of  these  conditions,  the  attack  of  measles  must 
he  looked  upon  merely  as  one  of  the  predisjiosing  factors  in 
the  causation,  and  not  as  the  real  cause  of  the  disease. 

Chronic  broncho-pneumonia  or  chronic  bronchitis  with  a 
tendency  to  exacerbations  sometimes  results  from  the  acute 
Tjronchitis  and  broncho-pneumonia  of  measles,  and  emphysema, 
eolJapse  of  certain  parts  of  the  lung,  the  formation  of  bronchi- 
>ectatic  cavities  and  considerable  cardiac  embarrassment  may 
•ensue. 

But  the  sequelae  which  are,  perhaps,  to  be  most  dreaded, 
are  those  due  to  tuberculous  infections,  to  which  measles 
renders  children  peculiarly  liable.  It  is  not  uncommon  for 
[[Darents  who  bring  a  tuberculous  child  for  examination  to  state 
i:hat  the  child's  ill-health  dates  from  a  few  weeks  or  months 
after  a  severe  attack  of  measles. 

Tuberculous  meningitis,  broncho-pneumonia,  pulmon- 
ary catarrh,  adenitis,  and  peritonitis,  may  all  be  included 
.among  the  sequelae  of  measles. 

It  must  be  remembered,  also,  that,  short  of  the  occurrence 
«of  any  definite  complication  or  sequela,  it  is  very  common  to 
find  that  after  an  attack  of  measles  a  child  is  feeling  "below 
par,"  both  mentally  and  physically,  is  pallid,  listless  and 
easily  fatigued,  capricious  as  to  appetite  and  uncertain  as  to 
digestion,  and,  in  short,  presents  a  picture  of  impaired  vitality 
long  after  the  attack  of  measles  has  passed,  indicating  the 
necessity  for  very  special  watchfulness,  lest  he  should  fall  a 
victim,  in  his  vulnerable  condition,  to  some  other  infection. 


Measles.  261 

Diagnosis. —  As  there  is  no  niicro-organisin  whicli  is 
known  to  be  the  causal  agent  of  measles,  diagnosis  must  be 
made  entirely  from,  the  clinical  features  of  the  case — the 
history,  the  character  of  the  eruption,  the  presence  of  catarrhal 
symptoms,  etc. 

The  diagnosis  of  measles  in  the  eruptive  stage  is 
not  usually  difficult.  The  rash,  if  well  developed,  is  very 
typical  and  the  associated  nasal,  conjunctival  and  pulmonary 
cataiYh  complete  a  picture  that  is  most  commonly  unmistak- 
able. The  history,  too,  of  a  catarrhal  stage  of  some  days' 
duration  preceding  the  eruption  is  almost  pathognomonic.  In 
some  cases,  however,  there  is  practically  no  catarrhal  stage, 
and  the  eruption  may  be  faint  and  limited  in  distribution, 
so  that  it  may  be  almost  impossible  to  differentiate  such  an 
attack  of  measles  from  German  measles  {q.v.). 

Sometimes  the  eruption  of  measles  is  quite  confluent  on 
the  face  and  body,  presenting  a  deep  uniform  redness,  and  in 
such  cases  it  may  be  difficult  to  distinguish  it  from  scarlet 
fever.,  Its  distribution  on  the  face,  however,  involving  as  it 
does  the  cheeks  and  circumoral  region,  whicli  are  usually  not 
invaded  by  the  rash  of  scarlatina,  will  help  to  distinguish  the 
two,  and  it  is  not  common  to  find  so  profuse  an  eruption 
unassociated  with  bronchial,  naso-pharyngeal  and  conjunctival 
catarrh,  while,  on  inquiry,  it  is  usually  found  that  the  appear- 
ance of  the  eruption  has  been  preceded  by  a  definite  catarrhal 
stage. 

It  is,  however,  in  the  pre-eruptive  catarrhal  stage  that 
the  diagnosis  of  measles  is  difficult  and  sometimes  impossible, 
while,  as  the  disease  is  highly  infectious  at  this  stage,  it  is 
of  the  utmost  importance  that  it  should  be  recognised  as  early 
as  possible.  A  "  heavy  cold  "  in  a  child,  accompanied  by 
lachrymation  and  photophobia,  however  slight,  should  always 
arouse  suspicion,  especially  if  any  fever  is  present,  and  it  is 
fortunate  that  in  the  majority  of  cases,  although  by  no  means 
in  all,  the  presence  of  "Koplik's  spots,"  described  above, 
will  enable  a  diagnosis  to  be  arrived  at  some  time  before  the 
eruption  appears.  These  spots  should  always  be  looked  for 
when  the  symptoms  are  at  all  suggestive  of  the  pre-eruptive 
stage  of  measles,  and  if  a  routine  examination  of  the  mouth 


262  Chapter  XVI. 

were  made  in  all  suspicious  cases,  it  is  probable  that  many 
epidemics  would  be  cut  short.  It  is  a  very  trite  remark  that 
when  the  rash  appears  the  mischief  is  already  done.  Unfor- 
tunately, the  early  cases  of  an  epidemic  are  seldom  brought 
under  observation  until  the  rash  has  appeared,  but  all  contacts 
•with  the  early  cases  ought  to  be  subjected  to  a  daily  scrutiny 
and  isolated  on  suspicion  when  the  first  signs  of  nasal  catarrh 
and  lachrymation  make  their  appearance,  and  a  careful  search 
for  the  "  spots  "  made  each  day,  so  that  a  diagnosis  may  be 
arrived  at  as  early  as  possible.  Man}^  cases,  however,  do  not 
show  these  "  spots,"  and  in  such  cases  one  must  simply  isolate 
on  suspicion  when  the  child  shows  symptoms  suggestive  of  the 
catarrhal  stage  and  w-atch  carefully  for  the  first  appearance 
of  eruption  or  the  prodromal  subcuticular  mottling  which  is 
sometimes  present.  The  association  of  the  case  with  other 
definite  cases  of  measles  can  be  sometimes  established,  and  it 
goes  without  saying  that  when  measles  is  known  to  be  rife  in 
a  neighbourhood,  all  cases  of  "heavy  cold"  in  children  are 
bound  to  be  looked  upon  as  suspect. 

Certain  drug-rashes,  notably  those  produced  by  copaiba 
and  chloral  may  closely  simulate  the  eruption  of  measles,  and 
inquiry  ought  always  to  be  made  with  regard  to  medicines 
taken  recently  in  investigating  a  suspicious  case. 

The  eruption  of  sraall-fox  in  its  papular  stage  is  often 
extremely  like  measles,  but  careful  palpation  of  the  papules 
will  reveal  the  ''  shotty  "  base  which  is  so  characteristic  of 
variola,  and  which  is  hot  met  with  in  measles. 

Treatment. — Froan  the  onset  of  the  catarrhal  stage 
the  patient  should  be  kept  absolutely  in  bed  and  particular 
attention  paid  to  the  avoidance  of  surface  chill.  It  is  the 
habit  at  present  rather  to  minimise  the  risk  of  chill,  but  there 
are  few  people  who  have  had  much  experience  in  the  manage- 
ment of  measles  but  will  admit  that  chill  during  the  catarrhal 
and  eruptive  stages  Avill  do  much  to  convert  a  simple  bronchial 
catarrh  into  a  definite  broncho-pneumonia,  or  induce  the 
development  of  grave  inflammation  of  the  eyes. 

At  the  beginning  of  the  eruptiA^e  stage,  the  development 
of  the  rash  may  be  aided  as  in  scarlet  fever  by  sponging,  with 
hot  water  and  mustard.     If  there  is  much  itching  of  the  skin. 


Measles.  263 

sponging  with  a  solution  of  bicarbonate  of  soda  in  hot  water 
or  Avitli  nietliylated  spirits  is  frequently  of  sc^'vice.  A  warm 
solution  of  carbolic  acid  (1-60)  or  the  liquor  carbonis  detergens 
may  be  used  if  these  fail  to  relieve. 

The  eyes  must  be  washed  out  several  times  daily  with  a 
soothing  antiseptic  lotion,  by  dipping  a  small  piece  of  cotton 
wool  in  the  lotion  and  squeezing  the  fluid  out  of  it,  holding 
the  eyelids  apart  with  the  fingers.  In  hospital,  a  douche-can 
with  a  rubber  tube  and  fine  glass  nozzle  may  be  used  instead 
of  the  cotton  avooI.  It  is  perhaps  unnecessary  to  say  that 
a  separate  nozzle  or  a  fresh  piece  of  cotton  wool  should  be 
used  for  each  patient  to  avoid  any  risk  of  spreading  infection. 
After  washing,  the  eyes  should  be  wdped  dry  with  a  piece  of 
cotton  wool  which  must  immediately  be  burnt.  I  have 
found  a  saturated  solution  of  boric  acid  in  distilled  water, 
with  1  dram  ofBattley's  solution  to  the  ounce,  to  be  an  effective 
and  soothing  lotion,  and  w"hen  there  is  much  pain  cocain  may 
be  added  to  form  a  1  per  cent,  solution.  At  night,  before  the 
patient  goes  to  sleep,  the  edges  of  the  eyelids  should  be  painted 
with  an  ointment,  having  lanoline  as  a  base  and  containing 
protargol  or  collargol  in  a  proportion  of  5-10  per  cent.  The 
protargol  or  collargol  ought  to  be  dissolved  in  a  few  minims 
of  distilled  water  before  being  added  to  the  langline. 
This  practice  will  lessen  the  incidence  of  blepharitis. 

If  the  conjunctivitis  be  severe,  with  much  swelling  of 
the  lids,  it  is  well  to  drop  a  little  of  a  1-1000  solution  of 
adrenalin  into  the  eye  before  washing  with  the  antiseptic 
lotion.  A  3  per  cent,  solution  of  nitrate  of  silver  may  also 
be  used  to  paint  the  inner  surface  of  the  swollen  lids,  after 
which  the  eye  should  be  washed  out  with  a  sterile  normal  salt 
solution. 

When  corneal  ulcer  has  appeared,  the  eye  should  be  put 
under  the  influence  of  atropine,  and  the  pupil  kept  well 
dilated.  If  the  ulcer  tends  to  spread,  especially  if  no  hypopyon 
is  present,  the  edges  should  be  touched  with  a  galvano-cautery, 
using  a  very  fine  point.  The  operation  is  a  delicate  one  and 
requires  some  skill,  so  that,  unless  the  practitioner  has  had 
considerable  experience  in  eye-work,  it  is  well  to  call  in  the 
assistance  of  an  ophthalmic  siirgeon. 

T   2 


264  Chapter  XYl. 

If  there  is  iritis,  pain  may  be  relieved  by  tlie  application 
of  leeches  to  the  temples,  and  by  the  administration  of  aspirin. 

When  pan  ophthalmitis  has  supervened,  it  is,  perhaps,  the 
best  practice  to  open  the  eyeball  freely  with  a  knife,  thus 
ensuring  proper  drainage  of  the  suppurating  cavity  and  less- 
ening the  risk  of  a  sympathetic  inflammation  in  the  sound  eye. 

Laryngitis  frequently  demands  special  treatment.  The 
patient  should  be  kept  in  a  warm  atmosphere  made  moist  by 
the  use  of  the  steam-kettle.  An  ordinary  kettle  with  a  funnel 
made  of  brown  paper  will  answer  the  purpose  well  where  there 
is  difficulty  in  obtaining  a  specially  constructed  article.  The 
use  of  ipecacuanha  wine  is  to  be  recommended,  as  in  croup, 
and  special  care  should  be  taken  to  procure  an  active  prepar- 
ation of  the  drug,  since  a  perfectly  inert  preparation  is  not 
infrequently  sold.  The  ipecacuanha  should  be  given  till 
vomiting  results.  Hot  poultices  or  fomentation  to  the  neck 
are  also  useful. 

Similar  treatment  should  be  adopted  when  the  laryngitis 
appears  in  the  eruptive  stage,  and,  in  addition,  when  there  is 
evidence  of  considerable  bronchial  catarrh,  poultices  to  the 
chest  may  be  employed  as  will  afterwards  be  described,  and 
one  or  two  minims  of  the  tincture  of  belladonna  may  be  given 
every  hour  in  combination  with  chloroform  water. 

In  the  laryngitis  which  appears  late  in  the  eruptive  stage 
or  after  the  rash  has  faded,  the  more  simple  methods  described 
above  may  be  quite  inefficacious,  and  the  obstruction  to 
breathing  may  be  so  great  as  l;o  necessitate  tracheotomy.  This 
operation  should  only  be  performed  as  a  last  resort,  because 
experience  shows  that  it  is  frequently'  unsuccessful  in  relieving 
the  condition,  which  is  often  associated  with  a  membranous 
tracheitis  and  bronchitis,  and  also  not  uncommonly  with 
broncho-pneumonia.  It  is  this  association,  quite  as  much  as 
the  frequently  membranous  character  of  the  laryngitis  itself, 
tliat  makes  the  condition  so  grave  and  so  often  fatal. 

The  mild  bronchial  catarrh  so  usually  met  with  in  measles 
requires  no  special  treatment,  but  when  a  capillary  bronchitis 
or  broncho-pneumonia  is  discovered  the  position  is  different. 
The  fever  is  often  high  and  may  be  controlled  by  tepid  or 
cold  spraying  and  compresses,   but  in  the  eruptive  stage  of 


Measles.  265 

measles  it  is  not  advisable  to  use  very  cold  applicaliojis.  No 
antipyretic  drug  should  he  given.  The  headache  which  accom- 
panies high  fever  is  best  treated  by  cold  applications  to  tlie 
forehead,  and  by  the  use  of  sodium  bromide  in  doses  suitable 
to  the  age  of  the  patient.  Hot  linseed  poultices  to  the  chest, 
containing  a  little  mustard,  often  relieve  distressed  breathing 
and  cyanosis,  but  should  not  be  allowed  to  remain  on  long. 
The  best  method  is  to  apply  the  poultice  for  some  twenty 
minutes,  and  have  a  jacket  of  Gamgee  tissue  warmed  mean- 
while. At  the  end  of  twenty  minutes  the  poultice  should  be 
removed,  the  chest  rapidly  dried  with  a  warm  towel  and  the 
warm  Gamgee  jacket  put  on.  Poultices  thus  used  may  be 
repeated  every  four  hours.  Poulticing  has  rather  gone  out 
of  fashion,  and  certainly  the  usual  practice  of  allowing  a 
linseed  poultice  to  remain  in  contact  with  the  chest  for  an 
hour,  until  it  is  almost  cold,  is  a  ridiculous  one,  but  I  have 
found,  especially  in  young  children,  that  mustard  and  linseed 
poultices  applied  as  above  described  are  extremely  useful  in 
promoting  easy  respiration  and  in  lessening  cough,  both  in 
bronchitis  and  broncho-pneumonia.  Inhalation  of  oxygen  is 
sometimes  of  service  where  there  is  much  cyanosis  and  cardiac 
failure. 

Dry  cupping  over  the  base  of  the  lung-s  or  the  epigastrium 
will  sometimes  relieve  the  feeling  of  suifocation,  and  venesec- 
tion has  been  performed  with  advantage,  when,  in  connection 
with  the  sense  of  suffocation,  there  is  much  cyanosis. 

Drug  treatment  must  be  suited  to  the  age  of  the  patient. 
It  is  useless  to  give  expectorants  to  children  who  are  too  young 
to  expectorate,  and  it  will  often  be  found  necessarj^  to  give 
occasional  emetic  doses  of  ipecacuanha  to  children  up  to  four 
or  five  years  of  age,  to  help  them  to  get  rid  of  bronchial  and 
tracheal  mucus.  The  tincture  of  belladonna  is  said  by  many 
to  be  a  useful  drug  in  capillar}^  bronchitis  and  broncho-pneu- 
monia. Its  action  is  supposed  to  be  in  the  direction  of  lessening 
the  secretion  in  the  trachea  and  bronchi,  and  it  also  acts  as 
an  antispasmodic  in  reducing  paroxysms  of  coughing.  A 
combination  of  belladonna  with  the  bromides  is  a  useful 
general  sedative  and  hypnotic. 


266  Chapter  XVI. 

In  a  certain  proportion  of  eases  rlionchi  and  rales  and  even 
evidence  of  patches  of  consolidation  persist  in  the  lungs  long 
after  the  temperatnre  has  come  down  to  normal  and  acute 
distress  has  passed  away.  When  such  a  chronic  condition  is 
established,  a  different  line  of  treatment  must  be  adopted  from 
that  employed  during  the  acuter  stages  of  the  complication. 

If  the  weather  is  warm  and  sunny,  the  patient  ought  to 
be  in  the  open  air  as  much  as  possible,  preferably  lying  doAvn. 
In  hospital,  the  children's  beds  should  be  moved  out  of  the 
ward  into  the  sun  for  the  greater  part  of  the  day.  Under 
this  method  of  treatment  the  resolution  of  a  bronchitis  or 
broncho-pneumonia  will  often  proceed  rapidly  after  hanging 
fire  for  weeks.  Friction  of  the  chest  with  the  hands  night 
and  morning  for  some  twenty  minutes  at  a  time,  using 
camphorated  oil  as  a  lubricant,  also  promotes  resolution.  The 
iodide  of  ammonium  in  small  doses  and  the  syrup  of  the  iodide 
of  iron  are  useful  in  cases  where  resolution  is  slow  and  they 
should  be  used  in  combination.  Where  areas  of  condensation 
remain  in  the  lung  after  rales  and  rlionchi  have  practically  dis- 
appeared, breathing  exercises  may  I)e  employed.  Post-nasal 
adenoids  and  hj^pertrophied  tonsils  should  be  looked  for  and 
removed  if  present. 

In  all  cases  where  the  resolution  of  a  bronchial  catarrh 
or  broncho-pneumonia  is  slow,  and  especially  if  the  condition 
is  liable  to  exacerbation,  sputum  ought  to  be  obtained  for 
examination  for  the  bacillus  of  tubercle.  When  the  child  is 
too  young  to  expectorate,  sufficient  sputum  may  be  obtained  for 
staining  by  introducing  a  finger  into  the  mouth  at  the  end  of 
a  cough  and  sweeping  it  round  the  pharynx. 

In  spite  of  all  precautions,  bronchiectasis  may  occur  and 
the  resulting  cavity  or  cavities  may  be  very  offensive.  "Open- 
air"  treatment  and  oil  of  creosote  may  be  of  assistance  in  the 
treatmeiit  of  such  cases.  The  creosote  may  be  given  internally 
or  in  the  form  of  a  dry  inhalation  combined  with  the  ethereal 
tincture  of  iodine,  oil  of  eucalyptus,  and  spirit  of  chloroform, 
in  equal  parts,  10  drops  of  the  mixture  being  used  in  a  Squire's 
oro-nasal  inhaler  and  renewed  every  hour.  The  inhaler  should 
be  worn  constantly  except  at  meal  times. 

Pleural  effusion   must  be  treated  on  ordinary  lines,   the 


MeasJrs.  207 

treatment  depending  largely  on  tJio  size  ol'  tlio  (ilTiisioi),  its 
duration  and  its  character,  wlietlier  tuberculous  or  simple. 

Empyema  should  be  dealt  with  surgically  witli  as  little 
delay  as  possible. 

If  cervical  adenitu  is  present  and  suppuration  lias  not 
occurred,  the  inflamed  gland  should  be  covered  with  Gamgee 
tissue  and  any  fricton  of  the  part  avoided.  After  the  occur- 
rence of  suppuration  the  abscess  must  be  opened  with  due  anti- 
septic precautions,  and  dressed  daily  with  moist  carbolic 
dressings. 

The  treatment  of  otitis  media  is  similar  to  that  described 
in  the  chapter  on  scarlet  fever. 

Diarrhoea  is  often  troublesome  and  necessitates  careful 
feeding.  It  is  sometimes  sufficient  for  treatment  to  wash  out 
the  lower  bowel  daily  with  warm  water,  but  in  many  cases 
it  will  be  necessary  to  use  small  and  frequently  repeated  doses 
of  grey  powder  with  bicarbonate  of  soda  and  carbonate  of 
bismuth.  Sometimes  a  little  Pulv.  Rhei  Co.  combined  with 
bismuth  is  very  useful.  A  small  dose  of  castor  oil  should  be 
given  before  any  other  treatment  is  begun. 

In  a  few  cases  the  stools  contain  some  blood  and  much 
mucus,  and  when  this  form  of  dysenteric  diarrhoea  is  present 
small  doses  of  castor  oil  may  be  given  daily,  and  a  little 
Dover's  powder  should  be  added  to  the  mixture  of  grey  powder, 
bicarbonate  of  soda  and  bismuth  described  above. 

Stomatitis  is  often  troublesome,  and  needs  very  special 
care,  especially  in  weakly  and  cachectic  children.  The  mouth 
should  be  gently  swabbed  out  every  three  or  four  hours  with 
a  solution  of  sodium  bi-borate  or  boroglyceride,  especially 
after  feeding.  It  may  be  well  to  intermit  milk-feeding  for 
a  day  or  two  and  feed  the  child  on  soups,  barley  water  and 
albumen  water  when  the  stomatitis  is  at  all  obstinate. 

Cancriivi  oris  is  occasionally  met  with  as  a  sequel  of 
stomatitis  when  the  child  is  of  poor  physique  and  has  been, 
perhaps,  weakened  by  a  previous  illness.  Operative  interfer- 
ence is  of  little  service  in  such  conditions,  and  it  is  best  to 
keep  the  affected  part  as  clean  as  possible,  dressing  it  with 
a  mixture  of  iodoform  and  boric  acid  powder  and  dry  cotton 
wool   or   cellulose   tissue,    until    the   extent   of   the   slough    is 


268  Chapter  XVI. 

defined.  After  the  extent  of  the  slough  is  apparent,  scraping 
tlie  part  and  applying  powerful  antiseptics  has  been  followed 
in  some  cases  by  healing,  but  the  low  resistance  of  the  tissues 
generally  makes  such  procedure  of  little  avail  in  most  cases. 
Arsenic  and  iron  may  be  given,  even  to  very  young  children, 
in  suitable  doses,  and  a  few  drams  of  port  wine  three  or 
four  times  a  day  may  encourage  appetite,  which  tends  to  be 
poor  and  capricious,  and  aid  digestion.  The  condition  is  a 
grave  one,  indicating  as  it  does  an  extremely  low  vitality, 
and  in  spite  of  all  efforts  towards  cure,  is  usually  the  indication 
of  a  fatal  termination. 

Noma  is  of  less  grave  significance,  and  lends  itself  more 
readily  to  surgical  interference.  The  general  principles  of 
treatment  are  similar  to  those  recommended  for  cancrum  oris. 

The  troublesome  complications  of  purulent  vulvitis  and 
vaginitis  which  occur  not  infrequently  in  children  of  poor 
physique  in  association  with  a  severe  attack  of  measles,  are 
best  treated  by  hot  douches  of  solutions  of  sodium  bi-carbonate, 
sodium  bi-borate  or  sodium  salicylate,  repeated  several  times 
a  day,  and  followed  by  the  application  to  the  inflamed  vulva 
of  an  ointment  of  lanoline,  containing  some  15  to  20  per  cent, 
of  one  of  the  albuminous  salts  of  silver,  such  as  protargol  or 
collargol.  Potassium  permanganate  in  fairly  strong  solution 
is  also  of  serAace. 

When  this  condition  arises  in  hospital,  or  where  several 
female  children  are  being  nursed  together,  the  great  con- 
tagiousness of  the  affection  must  be  remembered.  It  is  no 
uncommon  thing  to  have  an  epidemic  of  vulvitis  in  a  hospital 
ward,  and  when  cases  occur  in  a  ward  the  girls  should  be  separ- 
ated as  far  as  possible  from  each  other  by  boys.  The 
attendants  must  be  scrupulously  careful  to  avoid  all  risk  of 
carrying  the  infection  from  one  to  another,  and  after  douching 
and  washing  the  swabs  should  be  at  once  burned  before  the 
next  case  is  touched.  A  vulvar  pad  of  cotton  wool  should  be 
constantly  worn  by  the  child  to  lessen  the  risk  of  contamin- 
ation of  the  bedclothes. 

Rickets  following  on  measles  must  be  treated  on  the  usual 
lines.  The  patient  should  have  plenty  of  fresh  air,  and  if 
possible  sunshine.     Daring  the  earlier   and   acuter  stages   of 


Measles.  269 

the  affection,  exercise  is  not  advisable,  on  account  of  the 
increase  of  the  deformities  wliich  it  will  induce,  but  gentle 
daily  massage  of  the  limbs  is  very  beneficial.  Milk  should 
enter  very  largely  into  the  child's  dietary,  and  the  food  should 
be  light  and  fresh.  No  sweet  stuff  or  pastry  should  be  per- 
mitted, nor  any  salted  or  preserved  meat  or  fish.  Butter 
should  be  given  freely.  It  is,  of  course,  necessary  to  prohibit 
all  tea,  coffee  and  cocoa.  Of  drugs,  both  iron  and  the  lacto- 
phosphate  of  lime  are  useful,  as  is  cod  liver  oil,  when  it  is 
well  borne.  If  cod  liver  oil  tends  to  irritation  and  an  un- 
pleasant taste  in  the  mouth  for  some  time  afterwards,  it  should 
not  be  used,  since  pretty  much  the  same  effect  may  be  produced 
by  giving  plenty  of  butter  and  using  the  lactophosphate  o£ 
lime.  The  bowels  should  be  carefully  regulated,  and  small 
doses  of  grey  powder  thrice  daily  should  be  given  almost  as 
a  routine  during  the  early  stages  of  the  condition. 

Diet. — The  diet  in  measles  ehould  be  of  the  ordinary 
febrile  type,  and  must  be  regulated  according  to  the  condition 
of  the  patient. 

During  the  early  febrile  stage  and  so  long  as  there  is  any 
acute  bronchitis  or  broncho-pneumonia,  it  should  consist 
entirely  of  milk  and  soup,  with  a  little  egg  flip  occasionally. 
Water  may  be  given  freely.  As  the  temperature  subsides,  a 
semi-solid  dietary  should  be  given,  and,  a  few  days  later,  an 
ordinary  light  diet  may  be  resumed,  its  constituents  varying- 
with  the  patient's  age.  When  diarrhoea  or  dysenteric  diarrhoea 
are  present,  pre-digested  milk,  or  at  least  citrated  milk, 
will  be  necessary,  and  no  soup  save  a  little  chicken  tea  should 
be  given.  In  none  of  the  other  complications  is  a  special  diet 
necessary,  save  in  the  case  of  rickets.  The  diet  which  is 
advisable  in  rickets  has  already  been  discussed  under  the 
heading  of  "Treatment." 

Epidemiology. — Measles  is  endemic  in  all  Western  coun- 
tries, but  is  liable  to  frequent  epidemic  outbreaks.  It  is  more 
prevalent,  as  a  general  rule,  in  mid-winter  and  early  summer, 
than  during  other  seasons  of  the  year.  Epidemics  usually 
arise,  on  an  average,  about  once  every  two  years  or  so,  and  in 
populous  districts  the  disease  may  assume  a  very  virulent 
type   during  these   periods   of   epidemic   prevalence.     In  this 


270  Chapter  XVI. 

countiy  measles  is,  on  the  whole,  a  disease  of  childhood,  but 
adults  of  all  ages,  especially  those  who  from  their  early  up- 
briuging-  have  not  previously  had  the  disease,  are  liable  to 
fall  victims  to  it  during  an  epidemic.  This  is  particularly 
apparent  in  towns  whose  population  is  constantly  fed  by  immi- 
grants from  the  Western  Highlands  of  Scotland,  and  from 
the  West  of  Ireland.  In  isolated  communities,  such  as  the 
islands  of  the  Pacific,  the  inhabitants  are  liable  to  be  attacked 
with  equal  frequency  at  all  ages  when  measles  is  introduced 
after  a  long  period  of  freedom  from  the  disease. 

The  causal  agent  of  measles,  whatever  it  may  be,  seems  to 
be  present  in  the  nasal  passages  and  upper  parts  of  the  respira- 
tory tract  generally  from  the  first  onset  of  the  symptoms,  and 
the  disease  is  highly  infectious  from  the  very  beginning  of 
the  catarrhal  stage.  It  is  at  this  stage  that  measles  is 
dangerous  to  a  coinmunity,  on  acount  of  its  great  infectivity 
and  the  difficulty  of  its  recognition.  It  is  probable  that  the 
infection  is  capable,  to  some  extent,  of  surviving  in  fomites  for 
some  little  time,  although  it  is  certain  that  it  is  much  less 
resistant  in  this  respect  than  scarlet  fever.  In  any  case, 
measles  is  a  disease  which  is  much  more  likely  to  be  acquired 
by  direct  contact  with  patients  than  carried  from  one  to 
another  through  the  intermediary  of  a  third  and  perfectly 
healthy  person.  "Milk  epidemics"  are  not  known.  Schools 
are  the  most  favourable  grounds  for  spreading  any  epidemic, 
especially  those  schools  which  are  attended  by  the  poorer 
classes  of  the  community,  both  because  the  children  are  under 
very  inadequate  observation  at  home,  and  also  because  in  such 
schools  the  mania  for  "  attendance  "  is  peculiarly  rampant. 

Period  of  Infectivity. — A  case  of  measles  is  infectious 
from  the  first  onset  of  the  catarrhal  symptoms,  and  must  be 
considered  as  infectious  until  at  least  a  fortnight  has  elapsed 
after  the  appearance  of  the  rash,  or  until  all  signs  of  catarrh 
have  disappeared  should  they  persist  for  a  longer  period. 

Death-rate. — The  death  rate  in  measles  is  very  variable 
in  difi'erent  districts  and  in  different  years.  It  tends  to  be  high 
during  the  periods  of  epidemic  prevalence,  and  is  highest 
between  the  ages  of  six  months  and  two  years.  Over  the  age 
of  ten  years,   the  mortality  is  practically  nil.     Between  the 


Mca.slrs.  271 

j/^ears  1885  and  1902,  12,362  cases  of  measles  were  adrnjlted  to 
Belvidere  Fever  Hospital,  Glasgow,  and  the  case-mortality  over 
all  was  9.1  per  cent.  Of  the  12,362  cases,  1,930  were  between 
the  ag-es  of  six  months  and  two  years,  and  among  these  the 
case-mortality  was  sliglitly  over  24.75  per  cent.  When 
measles  attacks  a  community  which  has  not  hitherto  suffered 
from  the  disease,  or  in  which  the  disease  has  not  appeared 
for  a  very  long*  time,  the  death-rate  is  much  higher  than  in 
an  ordinary  epidemic,  and  there  is  no  such  difference  in  the 
mortality  at  various  ages — the  death-rate  is  much  the  same  in 
adults  as  among  the  children. 

In  civilised  countries  the  death-rate  is  notably  higher 
among  those  of  the  poorer  classes  who  are  insufficiently  fed  and 
clothed,  and  who  live  under  the  worst  hygienic  surroundings 
as  regards  dirt  and  overcrowding. 

Second  and  even  third  attacks  of  measles  do  occur,  but  are 
not  very  common,  and  the  subsequent  attacks  seldom  attain  to 
the  severity  of  the  first.  It  seems  probable  that  many  alleged 
second  or  third  attacks  of  measles  have  really  been  German 
measles. 

Home  Prophylaxis.  —From  the  moment  that  measles  is 
suspected,  the  patient  should  be  strictly  isolated,  and  put  to 
bed.  To  wait  until  the  rash  has  appeared  before  isolating  the 
patient  is  quite  futile,  as  the  most  infectious  period  of  the 
disease  is  the  early  catarrhal  stage.  Although  the  infection 
remains  but  a  short  time  on  any  fomites,  the  attendant  should 
wear  an  overall  in  the  sick-room,  as  it  is  quite  possible  for  her 
to  convey  infection  to  others  in  the  same  house.  All  contacts 
should  be  carefully  watched  and  isolated  on  the  first  suspicion 
of  catarrh.  The  diagnosis  of  measles  in  contacts  may  be 
assisted  greatly  by  the  discovery  of  Koplik's  spots.  At  the 
conclusion  of  the  case,  the  sick-room  requires  careful  disin- 
fection, and  bedclothes  and  other  articles  which  have  been  in 
close  contact  with  the  patient  must  be  disinfected  by  steam  or 
b>y  a  solution  of  formalin  according  to  the  material  of  which 
they  are  made.  The  walls  should  be  exposed  to  formalin 
vapour.  It  is  not  necessary  to  be  so  particular  about  the  re- 
papering  and  washing  of  the  sick-room  as  in  the  case  of  scarlet 
iever. 


272  Chapter  XVI. 

Public  Health  Administration. — The  fact  that  measles  is 
uot  a  notifiable  disease  makes  it.  difficult  for  any  medical 
officer  of  health  to  control  an  epidemic  at  all  adequately,  and, 
although  it  would  be  of  great  advantage  to  have  measles  made 
notifiable,  the  added  expense  to  the  administration  of  any  large 
district  would  at  first  be  so  enormous  as  to  be  practically 
unjustifiable.  But  although  the  death-rate  of  measles  between 
the  ages  of  5  and  7  years  is  only  about  4  per  cent,  on  an 
average,  the  case-mortality  among  young  children  is  something 
over  24  per  cent,  as  we  have  already  seen,  and  thus,  while  the 
death-rate  among  young  children  at  school  is  not  such  as  to 
warrant  any  great  expense  on  the  part  of  the  community,  it  is 
evident  that  a  case-mortality  of  24  per  cent,  calls  for  some 
interference.  One  finds  that  young  children,  up  to  4  or  5 
years  of  age,  are  in  the  majority  of  cases  infected  by  older 
children  who  have  acquired  the  disease  at  school,  and  this  fact 
makes  one  think  that,  short  of  universal  notification,  much 
could  be  done  to  lessen  the  incidence  of  the  disease  among 
young  children  by  an  improved  system  of  administration  of  the 
disease  in  our  schools.  The  school  medical  officer  is  now  an 
accepted  fact,  and  a  s^^stem  of  school  notification  of  cases  of 
measles  would  enable  the  authorities  to  control  an  out- 
break at  an  earlier  stage  than  is  now  possible.  In  this  con- 
nection, a  careful  record  should  be  kept  of  the  infectious 
diseases  from  which  each  child  has  suffered  before  coming  to 
school  and  during  his  school  life.  When  a  case  of  measles  has 
occurred  in  a  class,  the  class  ought  to  be  closed  from  the  ninth 
to  the  fourteenth  day  after  the  occurrence  of  the  case,  per- 
mitting members  of  other  classes  in  the  school  to  go  on  working 
unless  they  happen  to  be  related  to  the  first  case.  In  this  way 
the  cases  which  were  infected  by  the  original  case  would  develop 
at  home  and  would  be  capable  of  observation  by  the  staff  of  the 
public  health  department,  and  the  necessity  for  closing  a  whole 
school  would  at  any  time  be  extremely  remote.  Thus  a  fairly 
effective  control  of  the  outbreak  would  be  possible  with  a 
minimum  loss  of  school  time. 

When  measles  occurs  in  the  home  of  any  child  attending 
school,  the  recommendations  of  Thomas  to  the  London  County 
Council  should  be  followed:  — 


Measles.  '21Z 

(1)  That  any  cliild  wlio  has  had  measles  and  is  not 
attending  an  infant  school  need  not  be  excluded. 

(2)  That  any  child  who  has  not  liad  measles  and  is 
attending  a  school  other  than  an  infant  school,  ought  to  be 
excluded  until  the  Monday  following  the  expiration  of  fourteen 
days  from  the  occurrence  of  the  case. 

(8)  That  any  child  attending  an  infant  school,  whether 
he  has  had  measles  or  not,  should  be  excluded  for  a  similar 
period. 

Such  measures  taken  with  regard  to  schools  would  obviate 
to  a  very  great  extent  the  necessity  for  universal  notification, 
which  cannot  be  urged  at  the  present  time  on  account  of  the 
expense  involved,  not  only  in  payment  of  notification  fees  and 
in  increase  in  the  personnel  of  the  public  health  offices,  but  also 
in  the  increase  of  hospital  accommodation  which  would  at  once 
become  necessary.  It  is  quite  unfair  to  tax  the  already  over- 
burdened ratepayer  to  meet  such  an  increase  in  expenditure, 
and  yet  something  more  is  required  than  is  at  present  under- 
taken. A  system  of  school  notification  and  closing,  not 
of  schools,  but  of  classes,  for  the  limited  time  indicated  above, 
would  seem  to  meet  the  necessity  of  the  case  in  a  fairly  satis- 
factory way,  so  long  as  the  measures  are  taken  promptly  on  the 
appearance  of  the  very  first  case,  and  not  delayed  until  second- 
ary cases  have  made  their  appearance.  Once  a  crop  of 
secondary  cases  have  appeared,  little  short  of  closing  a  whole 
school  will,  in  most  instances,  prevent  a  spread  of  the  disease 
which  may  be  very  considerable,  not  only  in  the  school  itself, 
but  in  the  district  which  it  supplies. 

The  public  health  department  ought  to  undertake  the 
investigation  of  all  doubtful  cases  at  the  request  of  the  prac- 
titioner in  attendance ;  should  see  that  isolation  is  complete ; 
and  when  complete  isolation  is  impossible,  see  that  the  patient 
is  removed  to  hospital  when  accommodation  is  available.  The 
department  ought  also  to  undertake  at  the  termination  of  the 
case  the  disinfection  of  rooms  or  houses  where  cases  of  measles 
have  occurred. 

The  onus  of  enforcing  the  quarantine-time  of  contacts  with 
regard  to  school  attendance  ought  to  fall  on  the  education 
authorities. 


(    274   ) 


GERMAN    MEASLES. 

Synonyms. — Rubella;  Epidemic  lloseola. 

German  :  llotlieln. 
French :   Rubeole. 

Definition. —  A  specific  and  infectious  feA^er,  liaving' 
a  short,  mild  course  and  a  characteristic  eruption.  The 
causal  agent  of  the  disease  has  not  been  discovered. 

Incubation  Period. —  The  incubation  period  of  German 
measles  must  be  calculated  as  between  twelve  and 
twenty-one  days,  but  in  considerably  more  than  half  the  cases 
it  is  somewhere  between  fourteen  and  eighteen  days. 

Rash. — The  rash  of  German  measles  has  many  points  in 
common  both  with  scarlet  fever  and  measles.  It  attacks  the 
face  first,  and  appears  there  as  discrete  papules,  larger  than 
the  punctate  erythematous  spots  of  scarlet  fever,  and  smaller 
and  less  raised  than  the  large  papules  of  measles.  Its  colour 
is  a  red  which  is  not  so  blue  as  the  eruption  of  measles,  and 
not  so  bright  red  as  the  rash  of  scarlatina,  resembling  rather 
the  colour  of  a  scarlatinal  eruption  that  is  just  beginning  to 
fade. 

As  it  appears  on  the  face,  the  circumoral  region  is  always 
invaded  by  the  rash,  a  distinction  between  this  rash  and  that 
of  scarlet  fever.  The  rash  on  the  face  is  usually  composed  of 
fairly  discrete  papules,  but  may  become  blotchy  from  the 
coalescence  of  groups  of  papules.  The  blotches  are,  however, 
seldom  as  large  as  are  found  in  measles.  The  rash  quickly 
invades  the  trunk  and  limbs,  and  appears  there  as  discrete, 
rather  faded-looking  red  spots,  scarcely  raised  above  skin 
level.       These  spots  tend  to  coalesce,   and  may  result    in    a 


German   Measles.  275 

generalised  eiythemu  closely  resembling  that  of  scarlet  fever, 
and,  as  the  eruption  tends  at  tlie  same  time  to  fade  on  the 
face,  and  especially  round  the  mouth,  the  resemblance  to 
scarlet  fever  may  be  very  great,  especially  if,  as  often  happens, 
the  physician  has  an  opportunity  of  seeing  tlie  eruption  for 
the  first  time  only  when  it  is  in  this  stage.  In  other  cases  the 
papules  remain  fairly  discrete,  save  for  some  blotches  in  the 
bends  of  the  elbows  and  on  the  forearms.  The  appearance  of 
the  rash  is  associated  in  most  cases  with  some  catarrh  of  the 
nose  and  throat  and  a  little  injection  of  the  conjunctiva,  but 
even  when  the  rash  is  j)rofuse  there  is  much  less  catarrh  than 
in  an  ordinary  case  of  measles.  The  fauces  and  tonsils  may 
be  a  little  injected,  and  sore  throat  complained  of,  but  there 
is  no  lachrymation  and  very  little  coryza. 

The  temperature  is  usually  raised  as  the  rash  appears,  but 
seldom  rises  above  100°  F.,  although,  ocasionally,  a  fairly 
high  pyrexia  is  developed  on  the  second  day  of  the  rash.  The 
temperature  usually  falls  to  normal  before  the  rash  fades. 
Some  cases,  even  with  a  quite  profuse  rash,  do  not  show  any 
pyrexia. 

The  duration  of  the  eruption  is  very  variable.  As  a  rule 
it  persists  for  some  twenty-four  to  forty-eight  hours,  but  some- 
times its  duration  is  only  twelve  hours,  while  it  may  last  as 
long  as  four  or  five  days.  It  is  not  at  all  uniform  in  degree 
all  over  the  body,  tending  to  fade  almost  completely  in  parts, 
and  then  to  become  re-intensified.  It  remains  most  uniform 
on  those  parts  which  are  kept  consistently  warm,  and  if  it 
shows  signs  of  fading  may  often  be  revived  by  the  application 
of  heat  to  the  skin. 

In  the  majority  of  cases  the  rash  appears  on  the  second  or 
third  day  of  illness,  but  is  frequently  the  first  sign  of  the 
disease  that  is  noticed. 

Symptoms  of  Invasion. — For  some  twenty-four  hours 
before  the  appearance  of  the  rash  the  patient  commonly 
suffers  from  catarrhal  symptoms,  which  are  usually  slight. 
The  conjunctiva  is  injected,  giving  the  ''pink-eye"  appear- 
ance on  which  so  much  stress  is  laid  by  Clement  Dukes,  but 
there  is  no  photophobia  or  lachrymation.     There  may  be  some 


276  Chapter  XVII . 

sore  tlii'oat,  and  the  mucous  nieiubraue  of  the  mouth,  fauces, 
aud  phaiynx  may  be  slightly  reddened.  The  patient  may 
sneeze  occasional!}-,  but  there  is  little,  if  any,  coryza. 

One  of  the  most  important  prodromal  signs  is  enlarge- 
ment of  the  cervical  and  occipital  lymphatic  glands.  This  is 
not  constant,  but  is  present  in  a  majority  of  cases,  and  is 
sometimes  so  marked  as  to  make  the  patient  quite 
uncomfortable,  and  the  accompanying  pain  may  be  consider- 
able. 

The  prodromal  symptoms  are  usually  somewhat  exag- 
gerated as  the  rash  appears.  In  association  with  the  slight 
catarrh  of  eyes,  nose  and  throat,  the  patient  may  suffer  from 
some  general  malaise  and  headache,  and  shivering  or  a  sen- 
sation of  chill  is  common.  Vomiting  is  rare,  although  some 
degree  of  nausea  is  present  in  a  fair  number  of  adult  cases. 

While  these  symptoms  of  invasion  are  present  in  a 
majority  of  cases,  it  is  frequently  found  that  the  appearance 
of  the  rash  is  the  first  indication  of  illness. 

In  some  instances  the  period  of  invasion  has  been 
observed  as  lasting  for  as  long  as  six  or  seven  days  before  the 
appearance  of  the  rash,  but  it  is  usually  of  much  shorter 
duration. 

Clinical  Types.  — German  measles  is  somewhat  protean 
as  regards  the  rash,  and  the  constitutional  symptoms 
are,  as  a  rule,  so  mild  as  to  be  almost  negligible.  A  typical 
case  is  one  in  which  after  a  day  or  two  of  slight  malaise  and 
signs  of  a  little  catarrh  of  the  nose  and  throat,  with  some 
pinkness  of  the  conjunctiva,  the  papular  rash  appears  on  the 
face  and  the  temperature  is  found  to  be  slightly  raised  above 
the  normal.  In  the  course  of  the  day  the  rash  spreads  to 
the  trunk  and  limbs,  and  rapidly  becomes  scarlatiniform  in 
character  on  the  trunk,  while  on  the  limbs  it  preserves  a 
definitely  papular  type,  with  blotches  on  the  forearm  and  at 
the  bend  of  the  elbow.  As  the  rash  becomes  fully  developed 
on  the  trunk  and  limbs  it  fades  on  the  face,  and,  indeed,  one 
of  the  most  characteristic  features  of  this  eruption  is  that 
it  may  show  great  variation  in  intensity  on  various  parts 
of  the  body  at  the  same  time.  On  the  same  area,  too,  the 
rash    may    fade   and    revive   within    an    hour    or    two.     The 


German    Measles.  277 

temperature  reniaius  raised  for  ,soinc  tliirty-six  Iiours,  and  then 
falls  to  normal,  and  the  rash  has  faded,  in  most  cases,  within 
twenty-four  liours.  Some  degree  of  descjuamation  always 
follows,  usually  of  a  fine  powdery  kind,  beginning  almost 
immediately  on  the  disappearance  of  the  rasli,  and  lasting  for 
from  two  or  three  days  up  to  a  week  or  ten  days.  The  more 
profuse  the  rash,  the  more  definite  the  desquamation,  which, 
however  profuse,  never  occurs  in  large  flakes  as  in  scarlet 
fever.  In  an  ordinary  case  the  patient  is  quite  well  after 
the  desquamation  is  complete,  but  in  naturally  weak  chil- 
dren a  certain  amount  of  impaired  general  health  may  persist 
for  some  weeks. 

It  is  extremely  uncommon  to  find  a  type  of  case  more 
severe  than  is  indicated  above.  Cheadle  has  described  some 
types  of  the  disease  in  which  severe  laryngeal  and  bronchial 
symptoms  have  existed,  but  these  are  so  unusual  in  rubella, 
a]id  so  common  in  measles,  that  the  question  arises  as  to 
whether  the  cases  described  by  Cheadle  were  not  really  cases 
of  measles,  although  they  had  all  had  measles  previously. 

In  some  cases  catarrhal  symptoms  are  almost  entirely 
absent,  and  the  only  concomitant  of  the  rash  may  be  the 
"pink-eye"   which  is  so   common  in   German  measles. 

The  character  of  the  rash  varies  greatlj^  in  different 
epidemics.  In  one  tlie  rash  may  be  very  constantly  scarlati- 
niform  in  character,  while  in  another  it  assumes  the  blotchy 
form,  which  is  difficult  to   distinguish  from  true  measles. 

In  the  severe  cases  described  by  Cheadle  the  rash  was 
dark  purple  in  colour,  and  tended  to  be  ''fixed,"  and  it  is 
possible  that  these  cases  indicated  a  hsemorrhagic  type  of 
rubella.  Such  severe  cases  are  undoubtedly  very  rare  and 
on  the  whole  the  disease  is  extremely  benign  in  character. 

According  to  Clement  Dukes  it  is  possible  to  have  cases 
in  which  the  rash  is  so  slight  and  evanescent  as  to  escape 
notice,  and  the  manifestations  of  the  disease  are  confined  to 
a  slight  amount  of  "pink-eye"  and  a  little  catarrh  of  the 
nose  and  throat. 

Complications. —  Save  in  ver}^  weak  children,  accus- 
tomed to  bronchial  catarrh,  it  is  unusual  to  meet  with  any 


U. 


278  Chapter  XVII. 

complications  in  a  case  of  rubella,  but  in  such  children 
broncliial  catarrli  or  laryngitis  may  occur  and  even  prove 
fatal. 

Sequelae. — Tliese  are  also  practically  unknown  in 
rubella,  beyond  some  impairment  of  general  health  for  some 
months,  but  in  children  who  have  suffered  from  some  wasting 
disease  previous  to  the  attack  of  rubella,  the  attack  appears 
sometimes  to  hasten  the  wasting  process,  and  may  accelerate 
death  from  asthenia. 

Diagnosis.  —  In  an  epidemic  of  rubella  there  is  often 
much  dijiiiculty  in  recognising  the  first  few  cases;  later  cases 
present  less  difficulty  on  account  of  association  and  because 
of  their  comparatively  long  period  of  incubation,  which  tends 
to  distinguish  them  from  scarlet  fever  and  measles.  But  if 
scarlet  fever  and  measles  happen  to  be  epidemic  at  the  time, 
there  is  always  considerable  difficulty  in  making  a  diagnosis 
of  rubella. 

Apart  from  the  differentiation  of  rubella  from  scarlet 
fever  and  measles,  it  is  sometimes  necessary  to  distinguish  it 
from  eruptions  produced  by  drugs,  enemata,  or  errors  in  diet. 
The  protean  character  of  such  eruptions  does  not  help  in  their 
differentiation  from  rubella,  associated  as  they  are  with  little 
or  no  constitutional  disturbances,  but  what  is  of  importance 
is  the  fact  that  in  almost  all  such  rashes  areas  of  a  definitely 
urticarial  type  are  present. 

The  greatest  difficulties  in  diagnosis,  however,  arise  in 
the  differentiation  between  German  measles  and  mild  cases 
of  scarlet  fever  and  measles. 

In  German  measles  the  rash  on  the  body  may  be  strongly 
suggestive  of  scarlet  fever,  the  temperature  may  be  elevated, 
there  may  be  little  or  no  nasal  catarrh,  the  fauces  and  tonsils 
may  be  distinctly  red,  and  there  may  be  some  mottling  of  the 
soft  palate.  The  tongue,  however,  does  not  show  the  enlarge- 
ment of  papillae  which  is  common  even  in  a  mild  case  of 
scarlet  fever,  and  there  is  usually  some  definite  pinkness  of 
the  conjunctiva.  It  is  to  be  remembered,  too,  that  the  rash, 
while  definitely  scarlatiniform  on  the  body,  is  likely  to  show  a 
different  character  on  the  leg  and  the  dorsum  of  the  foot,  where 


German   Measles.  219 

it  has  made  its  uppcarance  Jatcfst.  Oji  tliese  areas  it  usually 
shows  the  distinctly  papular  character  above  described,  the 
papules  being-  of  a  faded  red  colour,  and  raised  only  slig'litly 
above  skin-level.  The  occurrence  of  vomiting  or  deftjiite 
shivering  during  the  period  of  invasion  would  be  strongly 
suggestive  of  the  attack  being  scarlatina  and  not  German 
measles,  and  the  presence  of  albumin  in  the  urine  would  also 
point  in  the  same  direction,  although  this  sign  is  so  seldom 
present  in  mild  cases  of  scarlatina  as  to  be  of  small  practical 
importance  in  differentiation. 

It  may  be  a  matter  of  considerable  difficulty  to  distin- 
guish a  case  of  German  measles  from  a  mild  case  of  true 
o 

measles.  The  cases  of  German  measles  which  are  most  likely 
to  be  mistaken  for  true  measles  are  those  in  which,  when  the 
patient  is  seen,  the  rash  has  not  yet  disappeared  from  the 
face.  It  is  true  that  as  a  rule  the  discrete  circular  papules  of 
German  measles  do  not  tend  to  run  into  irregularly  shaped 
blotches,  as  do  the  papules  in  measles,  but  occasionally  the 
blotchy  appearance  on  the  face  and  arms  in  German  measles 
is  sufficiently  marked  to  render  the  differentiation  from 
true  measles  a  not  altogether  easy  matter.  The  colour  of 
the  rash,  however,  in  German  measles,  is  much  paler  and 
more  faded  looking  than  the  eruption  of  true  measles,  and 
the  papules  are  not  nearly  so  much  elevated  above  the  skin. 
In  German  measles,  too,  there  is  usually,  besides  the  papular 
eruption,  a  certain  amount  of  diffuse  erythema  in  those  areas 
invaded  by  the  rash,  which  renders  the  appearance  fairly  dis- 
tinctive from  true  measles,  in  which  the  purplish  blotches  are 
set  in  skin  that  is  quite  white,  and  not  invaded  by  a  general 
blush.  A  measles  rash  in  a  very  early  stage  is  not  unlike 
the  rash  of  German  measles,  except  that  it  has  no  accom- 
panying erythema,  but  in  most  cases  of  measles,  even  as  the 
rash  is  coming  out,  "Koplik's  spots"  are  usually  to  be 
found.  These  spots  are  never  seen  in  cases  of  German 
measles.  The  appearance  of  the  eyes,  too,  is  very  different 
in  the  two  diseases.  While  in  German  measles  the  conjunc- 
tiva is  usually  very  definitely  pink,  there  is  no  such  suffusion 
of  the  eyes  and  lachrymation ,  with  swelling  of  the  lids  and 
photophobia,  as  may  be  met  with  even  in  a  mild  case  of  true 

c  2 


280  Chapter  XVII. 

measles  wlieie  (lie  rise  iu  temperature  may  be  quite  trivial. 
There  is  a  very  considerable  difference,  too,  in  the  severity 
of.  the  symptoms  of  invasion.  In  true  measles  a  well-marked 
catarrhal  period,  lasting  for  several  days,  is  the  rule,  and  a 
troublesome  frequent  cough,  with  sneezing  and  hoarseness, 
accompanied  by  definite  coryza,  are  common  in  all  cases  of 
true  measles,  however  mild.  It  is  true,  certainly,  that  a 
catarrhal  stage  of  several  days  may  precede  the  appearance 
of  the  rash  in  German  measles,  but  the  symptoms  during 
this  period  are  very  slight.  Cough  is  not  frequent,  sneezing 
is  also  infrequent,  laryngeal  symptoms  are  even  rarer,  and 
the  amount  of  coryza  present  is  \erj  trivial  indeed.  Another 
point  of  importance  in  a  differential  diagnosis  of  the  two 
diseases  is  that  in  German  measles  a  history  of  "  stiff  neck," 
associated  with  some  enlargement  of  the  h^-mphatic  glands  in 
the  posterior  cervical  region  and  occipital  region  is  not  at 
all  uncommon.  Such  a  condition  may  be  said  to  be  unknown 
in  measles. 

Besides  the  appearance  of  "Koplik's  spots  "  in  the  mouth, 
it  may  be  said  roughly  that,  while  the  mucous  membrane  of 
the  mouth  is  always  inflamed  and  covered  with  secretion  in 
measles,  this  is  never  the  case  in  German  measles,  but  in 
both  diseases  a  certain  amount  of  mottling  of  the  palate  may 
be  seen,  although  this  is  much  more  common  in  true  measles 
than  in  rubella. 

In  hospital  practice,  and  indeed  in  private  practice  of  a 
certain  kind,  too  much  stress  must  not  be  laid  upon  the 
enlargement  of  glands  in  the  diagnosis  of  German  measles. 
In  children,  where  little  attention  has  been  directed  to  keejjing 
the  head  clean,  such  enlargement  is  extremely  common  in 
association  with  an  irritative  and  eczematous  condition  of  the 
scalp,  and  enlargement  of  the  inguinal  and  axillary  lymphatic 
glands  is  also  not  uncommon  in  badly  kept  children. 

Treatment. — In  a  disease  which  is  so  simple  in  its 
manifestations  as  German  measles,  treatment  need  not  be 
complicated.  The  patient  should  be  kept  in  bed  for  two  or 
three  days  after  the  disappearance  of  the  rash,  and  should  be 
isolated  altogether  for  ten  days  from  the  appearance  of  the 


Gervian   Measles.  281 

eruption.  In  liospital,  patients  may  be  permitted  to  go  out 
of  doors  a  coiiple  of  days  after  tbey  have  been  allowed  out  of 
bed. 

If  there  is  no  fever  even  during  the  eruptive  stage  there 
is  no  reason  to  limit  the  patient's  dietary  in  any  way.  If 
there  is  fever  it  is  wise  to  confine  the  patient  to  a  light  diet, 
not  necessarily  entirely  fluid,  until  the  pyrexia  subsides. 

In  the  few  cases  where  bronchitis  and  laryngitis  occur, 
these  conditions  may  be  treated  by  the  application  of  heat 
to  the  neck  and  chest,  by  the  use  of  a  steam  tent,  and  by 
Vin.  Ipecac.  It  is  very  rarely,  however,  that  such  condi- 
tions arise,  and  it  is  seldom  necessary  even  to  treat  cough. 

Epidemiology. — The  disease  occurs  in  epidemic  form, 
the  commonest  seasons  for  such  epidemics  being  spring 
and  early  summer. 

It  is  met  with  at  all  ages,  and  is  perhaps  more  commonly 
seen  among  adults  than  is  true  measles. 

It  is  highly  infectious,  but  the  infection  is  short-lived, 
and  is  generally  the  result  of  direct  contact  with  the  patient. 
It  is  very  doubtful  if  the  disease  can  be  carried  by  a  third 
person,  and  it  is  probable  that  fomites  play  a  very  small 
part  in  its  dissemination.  The  catarrhal  discharges  are 
probably  the  sources  from  which  the  infection  is  derived. 

It  is  the  usual  practice  to  isolate  patients  suffering  from 
German  measles  for  a  period  of  ten  days  after  the  appearance 
of  the  rash,  but  it  is  quite  possible  that  the  patients  are  not 
infectious  for  more  than  a  week. 

It  is  safe  to  say  that,  except  in  those  very  rare  cases  where 
the  disease  may  have  taken  on  a  malignant  form,  recovery 
always  takes  place.  Sometimes,  however,  an  attack  of 
German  measles  may  hasten  death  where  the  patient  is 
already  the  subject  of  advanced  tuberculosis,  or  some  other 
wasting  disease. 

It  is  possible  that  second  attacks  do  occur,  although  they 
are  very  rare. 

Home  Prophylaxis. — The  patient  should  be  isolated, 
but  no  such  rigid  precautions  are  necessary  on  the 
part  of  the  attendant  as  in  the  case  of  measles  and  scarlet 
fever.     At   the   termination   of  the   period    of   isolation    it   is 


282  Oiayter  XVII. 

probable  that  no  further  means  of  disinfection  is  necessary 
beyond  a  thorough  airing  and  cleaning  of  the  room  in  which 
the  patient  has  been  confined.  It  is  well,  perhaps,  to  have 
all  clothing  and  bedding  which  has  been  definitely  in  contact 
witli  the  patient  disinfected  by  some  suitable  means  before 
being  washed.  The  attendant  should,  of  course,  be  careful 
to  wash  the  hands  and  face  before  leaving  the  room,  and  it 
is  well,  as  a  matter  of  routine,  that  an  overall  should  be  worn 
in  the  sick-room. 

Public  Health  Administration.  —  The  local  authorities 
should  see  that  the  rooms  of  patients  who  have  suffered 
from  German  measles  are  properly  cleaned  and  aired 
after  the  termination  of  the  case,  and  they  must  be  prepared 
to  disinfect  clothing  and  bedding,  if  called  upon  to  do  so. 

Where  the  disease  breaks  out  in  a  school,  it  is  enough 
to  keep  such  contacts  as  have  not  already  had  the  disease 
away  from  school  from  the  eighth  to  the  twenty-first  day 
after  their  exposure  to  the  infection.  In  addition  to  this, 
all  contacts  should  be  observed  daily  with  regard  to  glands 
and  the  appearance  of  any  catarrhal  symptoms.  If  this  is 
done,  there  is  very  little  risk  of  a  second  crop  of  cases  appear- 
ing. The  occurrence  of  second  attacks  is  so  unusual  that  it 
is  not  necessary  to  quarantine  any  children  who  have  had  the 
disease  before. 


(  283  ) 


Chapter  XVIII. 

SMALL-POX. 

Synonym. — Variola. 
German:  Die  Pocken. 
French :  La  Petite  Verole. 

Definition. — An  acute  infectious  disease,  cliaracterised 
by  a  primary  and  secondary  fever  and  a  specific  erup- 
tion which  passes  through  the  stages  of  papule,  vesicle  and 
pustule. 

Incubation. — The  period  of  incubation  is  most  usually 
twelve  days,  but  it  may  be  as  long  as  fifteen  or  even 
twenty  days,  and  as  short  as  eight  or  nine.  Twelve  days  i%. 
however,  by  far  the  commonest  incubation  time. 

Symptoms  of  Invasion. — The  symptoms  of  invasion  are, 
in  the  main,  those  of  the  onset  of  any  acute  fever, 
namely,  headache,  nausea,  vomiting,  frontal  headache  and 
general  malaise,  accompanied  or  immediately  followed  by  a 
rise  of  temperature,  both  rapid  and  considerable.  But  the 
headache  of  the  early  days  of  small-pox  is  peculiarly  severe. 
I  have  heard  those  who  have  been  accustomed  to  suffer  from 
severe  headache  and  have  also  had  small-pos,  say  that  all 
other  headaches  were  slight  as  compared  to  that  from  which 
they  suffered  before  the  eruption  of  small-pox  appeared. 
Another  symptom  of  invasion  in  small-pox  that  is  more 
striking  than  in  the  case  of  other  acute  fevers  is  pain  in 
the  back.  The  pain  is  usually  situated  in  the  lumbar  region, 
and  is  curiously  severe  and  ''sickening"  in  character,  and 
often  travels  down  the  legs.  It  may  be  associated  with  defi- 
nite loss  of  power  in  the  lower  limbs.  The  symptoms  of 
invasion  may  be  ushered  in  by  a  sensation  of  chill  or  a  defi- 
nite rigor,  or,  in  the  case  of  children,  by  a  convulsion  or 
series  of  convulsions.     The  skin  is  usually  dry  and  hot,  but 


284  Chapter  XVIII. 

profuse  sweats  may  break  out  from  time  to  time.  It  is  quite 
impossible  to  prophesy  tlie  severity  of  an  attack  of  small-pox 
from  the  severity  and  character  of  the  initial  symptoms.  A 
severe  and  ultimately  fatal  case  may  be  ushered  in  by  com- 
paratively mild  symptoms  of  invasion,  while,  on  the  other 
hand,  intolerable  headache,  violent  vomiting  and  excru- 
ciating pain  in  the  lumbar  region  may  precede  an  attack  so 
mild  as  to  be  scarcely  recognisable.  The  pulse  during  the 
period  of  invasion  is  rapid  and  full,  with  no  marked  dicro- 
tism. 

Rash. — The  eruption  of  small-jjox  appears  between  the 
third  and  fourth  day  after  the  onset  of  the  symptoms  of 
invasion.  Its  appearance  is  coincident  with  a  fall  in  tem- 
perature and  a  general  amelioration  of  s3aiiptonis.  The  rasli 
appears  first  as  a  series  of  papules,  bright  red  in  colour,  and 
more  or  less  closely  set,  according  to  the  severity  of  the  case. 
Even  in  the  severest  confluent  cases  the  papules  are  usually 
seen  to  be  separate  from  each  other,  confluence  occurring  only 
as  the  eruption  develops.  The  papules  have  a  smooth  feeling 
to  the  touch,  and  very  soon  after  their  appearance  it  is  pos- 
sible to  appreciate  by  pressure  that  they  have  a  firm,  hard 
base — this  constitutes  the  "shotty"  character  of  the  eruption, 
which  is  so  often  described. 

The  eruption  appears  first  on  the  forehead,  next  on  the 
back  of  the  hands  and  front  of  the  wrists,  and  within  twenty- 
four  hours  appears  also  on  the  face,  neck  and  feet,  and  even, 
although  to  a  less  extent,  on  the  trunk.  It  may  be  said  that 
the  eruption  appears  first  on  those  parts  of  the  skin  which 
are  most  exposed  to  irritation  of  any  kind,  such  as  exposure 
to  air  or  chafing  from  clothing,  and  it  is  no  uncommon  thing 
to  find  a  closely  set  group  of  papules,  which  may  afterwards 
develop  into  confluent  pustules,  although  the  rash  elsewhere 
is  discrete,  occupying  a  position  in  the  lumbar  region  which 
marks  the  point  of  application  of  a  poultice,  fomentation  or 
plaster,  which  has  been  used  in  the  hope  of  relieving  the 
intolerable  backache  of  the  period  of  invasion. 

On  the  fiftli  or  sixth  day  a  vesicle  appears  on  the  summit 
of  the  papule,  and  rapidly  increases  in  size,  until  it  is 
circular,  tense,  and  presents  the  appearance  of  umbilication, 


Small-i)ox.  2S5 

having  a  little  depression  in  its  centre.  Careful  inspection 
will  show  that  the  vesicle  is  multilocular.  It  is  usual  to  find 
a  small  areola  of  injected  skin  round  the  vesicle  as  it  increases 
in  size,  even  before  suppuration  begins.  On  the  eighth  day 
the  umbilication  disappears,  and  the  vesicle  becomes  a 
greyish-yellow  pustule,  surrounded  by  a  deeply  injected 
areola,  and  the  skin  in  its  neighbourhood  becomes  swollen. 
The  temperature  again  rises,  and  the  general  symptoms  of 
toxaemia  return.  The  swelling  of  the  skin,  particularly  of 
the  face,  causes  a  feeling  of  tension  and  pain.  The  eyelids 
become  swollen  and  are  opened  with  difficulty,  and  there  is  a 
good  deal  of  swelling,  accompanied  by  pain,  of  the  ears,  lips, 
and  nose.  This  is  seen  even  in  a  discrete  case  of  some  severity^ 
and  when  the  elements  of  the  eruption  tend  to  run 
together — to  become  confluent — the  pain  and  discomfort  are 
greatly  aggravated.  In  an  ordinary  discrete  case  the  secon- 
dary fever  does  not  last  longer,  as  a  rule,  than  a  conple  of 
days  or  so,  at  the  end  of  which  the  pustules  begin  to  shrivel, 
and  the  temperature  falls.  The  pustules  become  dry  first  on 
the  face,  and  then  elsewhere,  following  naore  or  less  the  same 
order  as  the  appearance  of  the  papules,  and  by  the  four- 
teenth or  fifteenth  day  desquamation  may  be  well  advanced 
on  the  face. 

The  distribution  of  the  rash  is  usually  quite  typicaL 
The  face,  wrists,  hands,  forearms,  upper  part  of  the  back,, 
and  the  feet  are  usually  most  closely  covered  by  the  rash, 
while  as  a  rule  it  is  scanty  on  the  upper  arms,  the  abdomen,, 
groins,  and  lower  part  of  the  back  and  legs.  The  eruption  seldom 
invades  the  axilla.  The  mucous  membrane  of  the  mouth, 
pharynx  and  larjmx  may  be  affected,  even  in  ordinary  dis- 
crete cases,  with  resulting  great  discomfort  from  swelling 
of  these  parts. 

The  mature  pustules  may  rupture  and  form  a  fairly  large 
crust,  or  they  may  shrivel  up,  forming  a  much  smaller  crust. 
The  crusts  on  the  body  separate  quickly,  as  a  rule,  but  on 
the  hands  and  feet  they  may  linger  for  many  weeks.  A 
characteristic  point  about  the  eruption  of  small-pox  is  that  it 
appears  on  the  palms  of  the  hands  and  the  soles  of  the  feet, 
and  it  is  often  a  matter  of  great  difficulty  to  get  rid  of  the 


286  Chapter  XVIII. 

remains  of  the  desiccated  pustules  or  "cores"  from  beneath 
the  hard  epidermis  of  these  parts.  These  "cores"  appear  as 
little,  dark,  hard  masses  beneath,  possibly,  quite  unbroken 
skin,  and  if  punctured  with  a  needle  they  are  found  to  con- 
tain a"  little  treacly  substance,  which  is  easily  removed.  The 
appearance  of  these  "cores"  is  very  characteristic,  and  they 
have  often  been  the  means  whereby  it  has  been  definitely 
established  that  a  patient  has  been  suffering  from  small-pox 
when  the  disease  has  not  been  detected  in  the  acute  stages. 

Prodromal  rashes  of  various  kinds  have  been  described 
as  preceding  the  appearance  of  the  true  eruption.  They  may 
be  either  scarlatiniform  or  morbilliform  in  character,  and 
while  sometimes  generalised,  they  are  usually  limited  to  the 
lower  part  of  the  abdomen,  the  inner  part  of  the  thighs,  the 
sides  of  the  chest,  and  the  anterior  axillarj^  borders.  They 
may  also  be  found  on  the  extensor  surfaces.  Prodromal 
rashes  are  usually  more  or  less  "fixed,"  and  are  commonly 
associated  with  a  dusky  erythema.  They  appear  about  the 
second  day  of  illness.  The  appearance  of  one  at  least  of  these 
prodromal  rashes  may  be  said  to  be  absolutely  diagnostic  of 
•small-pox,  namely,  a  dusky,  brownish  erythema  with  small 
closely  set  petechiae,  which  forms,  when  the  patient  is  lying 
flat  on  the  back  with  the  legs  together,  a  triangle,  whose  base 
lies  across  the  lower  abdomen  at  a  level  with  the  lower  iliac 
regions,  and  whose  apex  is  a  little  way  above  the  knees.  This 
appearance  is  not  likely  to  be  forgotten  by  any  who  have  had 
the  opportunity  of  seeing  it,  and  it  is  met  with  fairly  fre- 
quently in  an  epidemic  of  any  extent.  The  prevalence  of 
prodromal  rashes  varies  very  greatly  in  different  epidemics. 
Clinical  Types. — Small-pox  is  usually  divided  into 
three  classes  :  (1)  Variola  Vera,  which  may  be  either  (a)  dis- 
crete, or  (b)  coufluent;  (2)  Hcemorrhagic  Small-pox;  and 
(3)  Varioloid,  a  modification  of  true  small-pox,  which  has 
appeared  since  the  introduction  of  vaccination. 

(1)  Variola  Vera  in  its  discrete  form  has  been  practically 
described  under  the  headings  of  "Symptoms  of  Invasion" 
and  "Eash." 

In  the  confluent  form  of  Variola  Vera  the  eruption  tends 
to  appear  on  the  third  rather  than  on  the  fourth  day.       The 


S'niall-i)ox.  287 

papules  appear  in  enormous  numbers,  being  especially  closely 
set  on  the  face,  neck,  wrists,  hands  and  feet,  and  upper  part 
of  the  back.  It  is  common  for  the  temperature  not  to  fall 
to  normal  as  the  rash  appears,  and  the  general  symptoms  of 
fever  do  not  quite  disappear.  As  the  eruption  matures,  the 
vesicles  run  together  until  the  whole  face,  neck,  scalp,  hands 
and  feet,  with  perhaps  the  shoulders  and  back,  are  covered 
with  a  mass  of  eruption,  which  resembles  a  surface  studded 
with  pearls,  so  closely  set  that  not  even  a  pin  could  be  put 
between  them.  The  confluent  eruption  is  curiously  smooth 
to  the  touch.  The  body  is  covered  with  vesicles,  in  some 
places  quite  discrete,  while  in  others  confluent  patches  appear. 
The  scalp,  lips,  mouth,  pharynx,  and  the  mucous  membrane 
of  the  nose  are  seen  to  be  studded  with  vesicles,  and  the 
patient  suffers  grave  discomfort  from  the  swelling  and  pain 
of  the  affected  parts. 

But  it  is  during  the  suppuration  of  the  vesicles  that 
the  patient's  discomfort  reaches  its  acme.  The  temperature 
rises  again  to  highly  febrile  registers.  Headache,  nausea, 
thirst  and  sleeplessness  are  common,  and  tlie  enormous  swell- 
ing of  the  head,  neck,  hands  and  feet  is  associated  with  great 
pain.  There  is  usually  a  considerable  amount  of  cervical 
adenitis.  The  eyelids  are  swollen  and  cedematous,  and 
cannot  be  opened ;  pustules  may  invade  the  conjunctiva.  The 
ears  are  covered  with  the  confluent  eruption,  and  are  very- 
painful.  To  add  to  the  patient's  troubles,  diarrhoea  is  com- 
mon and  necessitates  frequent  handling  of  the  patient  by  his 
attendant,  a  process  which  is  always  to  be  avoided  as  much 
as  possible  on  account  of  the  risk  of  breaking  the  skin.  In 
no  other  disease  does  the  patient  present  such  a  terrible 
appearance  as  in  the  pustular  stage  of  a  confluent  attack  of 
small-pox.  His  head,  hands  and  face  are  bloated  out  of  all 
human  semblance,  he  is  an  offence  to  eyes  and  nose,  and  he 
lies,  delirious  or  semi-comatose,  a  mere  mass  of  superficial 
suppuration.  He  is  an  anachronism,  a  relic  of  the  days 
when  medicine  was  in  its  infancy  and  sanitation  non-existent, 
the  victim  of  the  most  loathsome  plague  that  ever  struck 
humanity. 

In  fatal   cases,   the  pulse  grows  feeble  and  rapid   about 


288  Chapter  XVIII. 

the  tenth  or  eleventh  day,  subsiiltus  tendinum  is  present, 
delirium  is  marked,  diarrhoea  may  occur,  and  the  patient 
dies  from  toxaemia  and  general  asthenia. 

"When  recovery  takes  place,  the  patient  enters  on  the 
stage  of  desiccation  about  the  twelfth  day.  The  tempera- 
ture falls,  the  pustules  dry  up,  forming  a  scab  or  "  crust," 
and  the  subcutaneous  oedema  subsides.  Delirium  and  sleep- 
lessness are  lessened,  but  the  patient  is  weak,  and  often  shows 
signs  of  profound  jDhysical  exhaustion,  and  still  needs  watch- 
ful care.  The  process  of  "crusting"  is  usually  complete 
about  the  fourteenth  to  the  sixteenth  day  of  illness,  and,  as 
it  is  completed,  desquamation  of  the  crusts  begins,  but  certain 
of  the  crusts  may  adhere  for  a  long  time  unless  some  assist- 
ance is  given.  The  crusts  tend  to  persist  longest  on  the  hard 
skin  of  the  palmar  surfaces  of  the  hands  and  fingers  and  on 
the  soles  of  the  feet.  In  these  situations  small  ''cores" 
may  persist  for  weeks  unless  removed  by  the  help  of  a  large 
needle.  These  cores  show  as  small,  hard,  dark  brown  or 
black  masses  buried  beneath  the  skin,  and,  when  punctured, 
are  found  to  contain  a  dark  treacly  substance,  which  is  easily 
remoA-ed  by  the  needle.  After  the  crusts  have  desquamated, 
the  site  which  they  have  occupied  is  seen  to  be  much  red- 
dened and  in  parts  ulcerated,  but  the  patient  becomes  once 
more  recognisable  as  a  human  being.  If  no  complications 
occur  the  patient's  condition  improves  rapidly;  his  appetite 
is  remarkable  and  his  capacity  for  sleep  extraordinary.  In 
confluent  cases  without  complications  convalescence  is  entered 
upon  toAvards  the  middle  or  end  of  the  third  week,  and  a 
week  later  the  patient,  although  still  unsightly  from  the 
scarred  and  reddened  face  and  scanty  hair,  may  feel  well  and 
able  to  get  about. 

The  discrete  form  of  true  small-pox  differs  from  the 
confluent  form  only  in  degree.  The  A^esicles  run  a  similar 
course,  are  associated  with  the  same  inflammatory  oedema  of 
the  skin,  and  pass  through  the  same  stages  of  pustulation  and 
desiccation  with  the  formation  of  "crusts."  The  tempera- 
ture and  pulse  fall  with  the  appearance  of  the  rash,  rise 
again  as  the  eruption  becomes  pustular  and  fall  as  desiccation 


SntuU-yox.  289 

progresses.  In  the  uncomplicated  discrete  variety,  con- 
Talescence   begins  ubout  tl)e   end  of  the   second  week. 

(2)  Hcemovvhaijic  Sinall-yox  or  Black  Small-pox  is, 
when  typical,  a,  form  of  the  disease  in  wliich  purpuric  spots 
entirely,  or  almost  entirely,  replace  the  ordinary  vesicular 
eruption.  The  onset  is  commonly  severe,  and  shortly  after 
the  symptoms  of  invasion  have  set  in,  the  skin  is  covered  with 
a  dark,  erythematous  rash.  In  the  course  of  a  day  or  two 
hfemorrhag-es  appear  in  the  skin,  most  marked  in  the  groins, 
the  flanks,  the  thig'hs,  the  bend  of  tlie  elbow,  the  axillary 
marg"ins,  the  neck  and  also  the  face.  These  haemorrhages 
are  at  first  small,  but  increase  rapidly  in  size  and  number. 
The  face,  where  it  is  not  the  seat  of  haemorrhages,  is  pale, 
and  the  patient  has  a  "large-eyed,"  anxious  look.  Fever 
runs  high  at  the  onset,  but  tends  to  fall  as  the  eruption 
appears,  and  death  may  occur  on  the  third  or  fourth  day  with 
a  temperature  of  only  about  100°  F.  The  pulse  becomes 
rapid,  very  soft  and  weak.  The  patient  is  painfully  con- 
scious of  his  increasing  weakness,  but  suffers  little  from  any- 
thing else  save  vsome  headache  and  an  intolerable  thirst.  The 
2iiind  remains' clear,  and,  indeed,  one  of  the  most  distressing 
features  of  this  form  of  the  disease  is  that  the  patient  may 
die  from  asthenia  with  a  mind  unclouded  up  to  the  last  few 
minutes  of  life. 

Hsemorrhages  occur  from  any  surface  which  is  capable  of 
bleeding,  from  the  mouth  and  nose,  from  the  stomach  and 
intestines,  from  the  kidneys  and  bladder.  The  urine  is  like 
porter.  In  women,  metrorrhagia  alwaj^s  occurs.  Subcon- 
junctival hsemorrhages  are  always  present,  and  the  iris  is  set 
in  a  purplish-black  surrounding.  As  the  disease  progresses 
not  only  do  the  haemorrhages  in  the  skin  increase  in  size  and 
number,  so  that  the  patient's  body  appears  to  be  splashed 
with  purple  paint,  especially  in  the  flanks,  the  neck  and  the 
upper  part  of  the  chest,  but  small  bruised  areas  appear  apart 
from  the  purpuric  rash.  Death  in  this  form  of  the  disease  is 
invariable,  and  usually  occurs  about  the  third  or  fourth  day, 
but  may  be  delayed  until  the  fifth  or  sixth.  If  life  is  prolonged 
beyond  the  fourth  or  fifth  day,  it  is  common  to  find  a  few 
vesicles  appearing  irregularly  among  the  patches  of  petechise. 


290  Chapter  XVIII. 

The  lisemorrhagic  type  of  small-pox  appears  "with  a  fre- 
quency which  varies  greatly  in  different  epidemics.  Some 
epidemics,  even  large  ones,  show  almost  no  hemorrhagic 
cases,-  while  in  others  the  hsemorrhagic  type  may  occur  so 
frequent!}'  as  to  make  up  some  1  or  2  per  cent,  of 
all  the  cases.  The  lisemorrhagic  type  is  by  no  means  confined 
to  unvaccinated  persons;  indeed,  it  would  seem  as  if  this  type 
of  the  disease  appears  with  almost  as  great  frequency  among 
persons  who  have  had  some  sort  of  vaccination  in  infancy  as 
among  those  who  have  never  been  vaccinated. 

Modifications  of  the  typical  hremorrhagic  small-pox  are 
frequently  met  with,  when  the  true  eruption  precedes  or  fol- 
lows immediately  on  the  appearance  of  the  lisemorrhagic  rash. 
In  this  form  the  haemorrhages  occupy  the  bases  of  the  vesicles 
and  the  skin  between  them.  The  vesicles  are  badly  developed 
and  irregular  in  distribution.  They  are  flat  and  empty,  and 
of  a  bluish  colour  from  the  haemorrhage  into  their  bases. 
The  face  is  swollen  and  purple,  and  the  skin  of  the  body 
generally  is  cyanosed.  The  eruption,  save  only  in  a  few  favour- 
able cases,  seldom  proceeds  to  pustulation.  In  such  cases  the 
patient's  mind  is  usually  clouded,  and  he  suffers  from  a 
muttering  delirium.  Bleeding  from  the  nose  and  hsematuria 
may  occur,  and  subconjunctival  haemorrhages  are  also 
frequent. 

Death,  although  the  usual,  is  not  the  invariable  termina- 
tion of  such  cases  and  is  longer  delayed  than  in  the  true 
''black  small-pox,"  occurring  usually  at  the  end  of  the  first 
week. 

HcBTnorrhage  into  the  vesicle  itself,  apart  from  any  other 
haemorrhagic  eruption,  may  be  seen  not  infrequently  in  severe 
cases  of  true  small-pox,  and  although  this  usually  indicates 
a  grave  condition  of  the  patient,  it  is  not  in  itself  a  sign  of 
anjdhing  unUvSual  in  the  case,  which  proceeds  on  the  normal 
lines  of  variola  vera,  and  should  not  be  included  among  the 
real  haemorrhagic  types  of  the  disease. 

(3)  Varioloid  is  a  modification  of  true  small-pox,  in 
which  the  eruption  aborts  in  the  vesicular  stage,  and  does  not 
go  on  to  pustulation. 


S'mall-pox.  291 

TJie  symptoms  of  onset  are  precisely  similar  to  those  met 
with  in  true  small-pox,  and  vary  as  much  in  intensity.  No 
clue  is  given  as  to  the  future  behaviour  of  the  case  by  either 
the  symptoms  of  invasion  or  the  early  appearance  of  the 
rash,  which  may  be  scanty  or  profuse,  and  preceded  or  not 
by  the  various  prodromal  eruptions.  The  initial  symptoms 
may  be  severe,  and  the  rash  profuse,  but,  after  the  primary 
fever  has  fallen,  there  is  no  secondary  rise,  and  the  attack 
terminates  with  the  drying-up  of  the  vesicles,  practically 
none  of  which  develop  into  pustules.  This  type  of  the  disease 
is  quite  benign. 

Complications. — The  complications  of  small-pox  are 
almost  all  connected  with  the  stage  of  pustulation,  and  are 
chiefly  the  result  of  a  pyogenic  infection  of  the  skin,  the 
eyes,  and  the  mucous  membrane  of  the  mouth,  throat,  and 
respiratory  tract.  The  more  severe  the  case,  the  more  likely 
is  it  that  complications  will  occur. 

In  confluent  or  semi-confluent  cases,  as  pustulation  passes 
on  to  crusting,  inflammation  of  the  skin  and  subcutaneous 
tissues  frequently  occurs,  and  a  cellulitis  may  be  produced 
which,  although  usually  limited,  may  be  extensive  and 
severe.  At  points  of  pressure  slougJiing  of  the  sJcin  and 
subcutaneous  tissues  may  occur.  This  is  particularly  com- 
mon over  the  sacrum  and  hips,  but  the  skin  over  the  shoulders, 
elbows,  knees  and  heels  may  also  be  affected.  Such  sloughs 
are  sometimes  very  deep,  so  that  the  upper  part  of  the  sacrum 
may  be  entirely  exposed,  or  one  or  other  hip- joint  may  be 
denuded  of  the  tissues  which  should  cover  it,  and  the  capsule 
of  the  joint  is  seen  forming  the  floor  of  the  pressure  sore, 
which  is  left  as  the  slough  separates. 

Affections  of  the  eye  are  frequently  met  with,  the  most 
usual  being  conjunctivitis,  corneal  ulcer  and  keratitis. 

The  eruption  of  small-pox  is  sometimes  present  on  the 
conjunctiva  itself,  and  a  certain  amount  of  conjunctivitis  is 
very  common,  even  in  comparatively  mild  cases.  It  is 
natural  enough,  considering  the  nature  of  the  eruption,  that 
a  corneal  ulcer  should  form  where  the  eruption  is  profuse, 
and,  while  in  most  cases  it  is  tractable  and  heals  reasonably 
well,    in    some    cases    it    spreads    with    great    rapidity    and 


292  Chapter  XVIII. 

may  produce  a  'pano'plitlialmitis  with  complete  destruction  of 
tlie  eye.  Blindness  may  also  result  from  keratitis,  when,  as 
sometimes  happens,  the  whole  cornea  is  involved.  In  many 
cases,  however,  the  keratitis  is  limited,  and  the  opacity  clears 
up  gradually,  but  sometimes  a  limited  keratitis  may  result  in 
the  formation  of  a  deep  perforating  ulcer.  If  the  ulcer  is 
not  very  large,  the  opacity  which  results  from  its  healing 
may  disappear,  but  it  is  more  often  permanent.  Keratitis  is 
usually  accompanied  by  photophobia,  and  increased  intra- 
ocular tension.  The  inflammation  commonly  begins  at  the 
outer  margin,  and  is  very  frequently  limited  to  about  a  half 
of  the  cornea.  Only  one  eye  may  be  affected,  and  where  both 
eyes  are  attacked,  one  is  usually  much  more  severely  affected 
than  the  other.  A  particularly  destructive  form  of  keratitis 
is  that  which  is  sometimes  met  with  in  severe  confluent  cases, 
in  which  there  is  no  photophobia  or  injection  of  the  conjunc- 
tiva. The  cornea  is  seen  to  be  dull,  quickly  becomes  cloudy, 
and  the  w^hole  cornea  may  become  opaque  in  twenty-four 
hours.  In  the  course  of  a  day  or  two  it  sloughs,  the  aqueous 
humour  is  discharged,  the  iris  prolapses,  and  the  lens  pro- 
trudes. A  complete  anterior  staphyloma  may  be  the  result, 
or  even  a  panophthalmitis.  In  some  cases  only  part  of  the 
cornea  sloughs,  and,  if  the  perforation  is  small,  only  a  small 
staphyloma  may  occur. 

Glossitis  is  sometimes  met  with,  and  sloughing  of  the 
fauces  and  soft  palate  may  result  in  the  formation  of  deep 
and  extensive  ulcers,  which  are  often  very  foul. 

Of  all  the  complications  of  small-pox  the  most  fatal  are 
those  which  are  connected  with  the  respiratory  tract.  In 
severe  cases  the  eruption  spreads  even  to  the  finer  bronchi,  so 
ihat  on  examination  of  the  lung  post  mortem  it  is  quite  recog- 
nisable, and  a  septic  bronchitis  or  hronclio-pneumonia  is  of 
frequent  occurrence  in  confluent  cases.  Lohar  pneumonia 
is  much  less  frequent,  but  is  also  met  with ;  pleurisy,  either 
dry  or  with  effusion,  is  rare.  Where  an  effusion  occurs  it  is 
usually  purulent. 

Slight  laryngitis,  as  shown  by  some  degree  of  hoarseness, 
is  a  very  common  complication,  and  if  it  remains  slight  has 
no  serious  significance.     If,  however,  it  is  severe  enough  to 


Small-pox.  293 

cause  complete  aj)honia,  or  if  there  is  definite  dyspnoea,  the 
outlook  is  extremely  grave.  Acute  o'.dema  of  the  fjlottis  may 
occur,  and  there  may  be  more  or  less  extensive  ulceration  of 
the  laryngeal  cartilages. 

Orchitis  is  not  infrequent,  aud  adenitis,  especially  of  the 
cervical  and  axillary  glands,  is  fairly  common,  usually  going 
on  to  suppuration. 

The  co7nplicatio7is  connected  ivith  tlic  nervous  system  are 
not  very  numerous.  Delirium,,  which  is  common  in  the  early 
febrile  stages,  occasionally  takes  on  an  acute  maniacal  type, 
and  a  few  cases  have  been  recorded  in  which  this  has 
persisted  for  some  weeks.  Peripheral  neuritis  is  uncommon. 
Paraplegia  sometimes  occurs,  and  this  is  frequently  a  very 
unfavourable  indication.  Some  degree  of  loss  of  power  of 
the  legs,  however,  is  not  very  rare,  in  association  with  the 
severe  lumbar  pain  which  is  so  usual  as  one  of  the  symp- 
toms of  invasion.  This  does  not  seem  to  be  due  to  a  peri- 
pheral neuritis,  but  is  more  likely  due  to  an  affection 
of  the  spinal  cord  or  meninges,  presumably  of  toxic  origin. 
The  condition  is  one  of  no  particular  gravity,  and,  although 
unusual  weakness  of  the  legs  is  apparent  during  convales- 
cence, with  some  exaggeration  of  the  knee-reflexes,  recovery 
takes  place  rapidly.  Hemiplegia  has  also  been  observed,  but 
possibly  only  as  an  accidental  and  intercurrent  affection. 

When  small-pox  is  complicated  by  pregnancy,  abortion 
occurs  with  a  frequency  which  varies  largely  with  the  age  of 
the  foetus  and  the  severity  of  the  attack;  i.e.,  the  older 
the  foetus  and  the  more  severe  the  attack,  the  greater  is  the 
chance  of  abortion.  It  occurs  in  all  hsemorrhagic  cases  who 
survive  beyond  the  third  or  fourth  day,  and  in  many  at  an 
earlier  period.  In  severe  confluent  cases,  also,  abortion 
always  occurs,  usually  during  the  vesicular  stage  of  the 
eruption.  In  less  severe  cases,  if  abortion  occurs  it 
does  so  most  commonly  in  the  second  or  third  week 
of  the  disease,  and  may  be  delayed  even  until  the 
patient  is  convalescent.  Severe  hsemorrhage  is  frequent, 
and  there  is  often  trouble  with  the  placenta.  Abortion  is 
fatal  in  all  lisemorrhagic,  and  in  most  confluent,  cases.  In 
discrete  and  varioloid  cases  the  outlook  for  the  mother  is  good. 


294  ChaiAer  XVIII. 

The  foetus  may  be  born  with  the  eruption,  or  may  develop  the 
disease  shortly  after  birth,  having  been  infected  in  utero. 
Sometimes  it  is  born  without  having  contracted  the  disease, 
and  may  be  rather  refractory  to  vaccination. 

Sequelae. — In  severe  cases,  where  there  has  been 
much  destruction  of  the  skin  during  the  stage  of  pustulation 
and  crusting,  pitting  is  the  result,  and  in  severe  confluent 
cases  the  scarring  may  be  so  considerable  as  to  distort  the 
eyelids,  the  mouth  or  the  nose.  The  scars  are  at  first  deeply 
pigmented,  but  they  ultimately  become  white. 

Blindness  may  result  from  keratitis  with  extensive 
sloughing. 

In  a  case  in  which  the  eruption  has  been  profuse  in  the 
scalp,  patches  of  baldness  are  frequently  left,  which,  how- 
ever, persist  only  for  a  short  time  unless  there  has  been  very 
unusual  destruction  of  the  scalp,  in  which  case  some  patches 
may  be  permanent. 

Diagnosis.  — A  case  of  small-pox  may  present  itself 
for  diagnosis  in  one  of  three  stages — in  the  stage  of  invasion, 
in  the  stage  of  eruption,  and  in  the  stage  of  desquamation 
when  all  signs  of  eruption  have  disappeared  except  pigmen- 
tation,  scarring,  and  the  small  buried  cores. 

Diagnosis  in  the  stage  of  invasion :  It  is  only  during  an 
epidemic  of  small-pox  that  there  is  the  slightest  chance  of 
diagnosing  a  case  at  this  period  of  the  disease.  The  symp- 
toms of  invasion  differ  so  little  from  the  symptoms  of  invasion 
of  any  other  acute  fever,  that  it  is  a  matter  of  extreme  doubt 
as  to  whether  any  case  could  be  diagnosed  as  small-pox  at 
this  time,  save  in  association  with  other  cases  which  are 
manifestly  variola.  It  is  true  that  the  headache  is  more 
intense,  and  that  the  backache  is  as  a  rule  of  far  greater 
severity  in  the  prodromal  stage  of  small-pox  than  in  any 
other  acute  feA'er,  but  one  cannot  establish  a  diagnosis  on 
this  alone.  It  is  only  where  the  prodromal  rash  of  a  pete- 
chial character,  limited  to  the  lower  abdomen  and  inner  side 
of  the  thighs,  occurs,  that  one  can  arrive  at  a  diagnosis  of 
small-pox  before  the  true  eruption  has  made  an  appearance. 
This  prodromal  rash,  however,  is  so  characteristic  of  the 
disease,    that    in   the    absence   of   any    other    definite   sign    of 


S'inall-'pox.  295 

small-pox,  apart  from  the  symptoms  ol'  invasion,  it  may  Ix* 
taken  as  absolutely  diag-nostic.  It  is  not  at  all  iufrequently 
seen  in  the  course  of  an  epidemic,  or  even  at  the  beginning  of 
an  epidemic,  and  it  is  of  the  greatest  importance  that 
physicians  should  be  familiar  with  this,  as  one  never  knows 
whether  the  recognition  of  a  case  of  small-jjox  in  an  early 
stage  may  not  be  the  means  of  limiting  an  epidemic,  which 
might  otherwise  reach   vast  proportions. 

Diagnosis  in  the  stage  of  erwption :  The  eruption  of 
small-pox,  especially  if  it  be  at  all  scanty,  may  be  confused 
in  the  papular  stage  with  measles  and  certain  drug  rashes, 
or  eA^en  with  syphilis,  while  in  the  vesicular  stage  it  may 
bear  a  striking  resemblance  to  the  eruption  of  chicken-pox, 
and  also  to  certain  types  of  pemphigus,  especially  the  syphi- 
litic variety  of  that  eruption. 

In  the  papular  stage,  the  eruption  of  small-pox  makes 
its  first  appearance  on  the  forehead,  spreading  to  the  face, 
neck,  scalp,  hands  and  feet.  The  papules  are  definitely 
slightly  raised  above  the  skin,  and  have  a  more  velvety  feeling 
to  the  touch  than  the  ordinary  eruption  of  measles.  The 
absence  of  corj^za  and  lachrymation  serve  to  differentiate  it 
from  the  early  eruption  of  measles,  and  there  is  no  tendency 
in  small-pox  for  the  papules  to  run  together  in  crescentic 
groups.  But  the  most  notable  feature  of  the  papular  stage 
of  the  eruption  of  variola  is  the  distinct  hardness  of  the  base 
of  the  papule,  which  is  usually  so  marked  as  to  give  the 
examining  fingers  the  feeling  as  if  small  shot  were  embedded 
in  the  skin.  This  condition  is  rare  in  measles,  and  even 
when  present  is  much  less  marked  than  in  small-pox.  The 
same  characters  tend  to  differentiate  the  small-pox  eruption 
from  any  diug  rash.  The  drug  rash  which  is  most  usually 
brought  up  for  differential  diagnosis  during  an  epidemic  of 
simall-pox  is  a  rash  produced  by  the  taking  of  copaiba,  and  a 
careful  enquiry  into  the  history  of  the  case  will  usually  serve 
to  bring  out  the  fact  that  the  drug  is  being  taken,  and  also 
the  reason  for  its  administration. 

One  must  remember,  however,  in  spite  of  the  definite 
statements  made  with  regard  to  the  '"^  shotty  "  character  of 
the  rash  in  small-pox  and  the  soft  character  of  the  papule  in 

X  2 


296  Chapter  XV 111. 

measles,  that  iu  certain  cases  of  sinall-pox  there  may  be  a 
total  absence  of  the  "sliott}- "  feeling,  and  in  some  cases  of 
measles  the  papules  on  the  forehead  may  be  unusually  hard, 
so  that  a  diiferential  diagnosis  niay  be  a  matter  of  extreme 
difficult}'.  Where  there  is  an}'  donbt  whateYer  in  the  mind 
of  the  j)liysician  the  case  must  be  isolated,  and  observed  with 
care,  until  such  time  as  the  appearance  or  non-appearance  of 
the  vesicular  eruption  places  the  matter  beyond  doubt.  In 
such  cases  the  patient  should  be  vaccinated  on  three  succes- 
sive days,  and  successful  vaccination  will  prove  that  the  case 
is  not  small-pox. 

Diagnosis  in  the  vesicular  stage :  It  is  not  likely  that 
a  typical  confluent  or  semi-confluent  eruption  of  small-pox 
will  be  mistaken  for  anything  else,  but  where  the  eruption  is 
scanty,  and  where  there  is  no  definite  association  known  with 
any  other  case  of  small-pox,  a  rather  scanty  small-pox  rash  in 
the  vesicular  stage  may  be  easily  mistaken  by  the  inexperi- 
enced for  a  moderate  eruption  of  chicken-pox.  There  are 
certain  definite  characters,  however,  presented  by  the  small- 
pox vesicle  which  are  not  presented  by  the  vesicle  of  chicken- 
pox.  The  small-pox  vesicle  is  circular,  shows  evidence  of 
loculation,  and  shows  a  small  depression  on  its  surface  or  umbi- 
lication.  The  loculation  of  the  vesicle  makes  it  very  firm  and 
resistant  to  pressure,  so  that  it  does  not  burst  when  pressed 
on  by  the  finger  with  anything  like  the  same  ease  as  the 
flabbier  unilocular  vesicle  of  chicken-pox,  which,  too,  has  no 
umbilication  on  its  surface,  no  hard  base,  and  very  little 
areola.  The  distribution,  also,  of  the  rash  of  small-pox 
serves  to  distinguish  it  very  largely  from  that  of  chicken-pox. 
Even  in  an  attack  of  chicken-pox  with  profuse  eruption  it  is 
very  rare  indeed  to  find  any  vesicles  on  the  palms  of  the 
hands  or  on  the  soles  of  the  feet,  whereas  even  in  a  case  of 
small-pox  with  a  rather  scanty  eruption  vesicles  are  usually 
found  in  these  situations,  although  not  always.  It  is  to  be 
remembered,  however,  that  the  vesicle  of  chicken-pox  is  some- 
times found  on  the  palms  of  the  hands  and  on  the  soles  of 
the  feet,  and,  where  this  is  so,  the  general  character  and 
distribution  of  the  eruption  must  be  considered  with  a  view 
to  the  differentiation  of  the  disease. 


S}ii(i]l-po.v.  297 

The  eruption  of  small-pox  always  follows  (m  a  definite 
period  of  invasion,  whereas  the  eruption  of  cliicken-pox  is 
usually  the  first  sign  of  the  disease.  The  eruption  of  small- 
pox follows  a  more  or  less  regular  sequence  in  appearance, 
and  the  rash  in  definite  areas  is  usually  at  the  same  stage, 
i.e.,  while  it  may  be  papular  on  the  back  and  vesicular  on 
the  face,  you  do  not  find  in  the  same  area  late  vesicles  and 
early  papules  together.  In  chicken-pox,  however,  one  finds 
on  a  few  square  inches  of  skin,  say  on  the  back,  papules, 
vesicles,  crusts,  and  scars  together,  indicating  the  fact  that 
the  eruption  has  come  out  in  successive  crops.  The  vesicle 
of  chicken-pox,  also,  tends  to  be  rather  oval  than  round;  the 
crust  and  the  scar  preserve  the  same  formation.  Sometimes 
the  vesicles  of  chicken-pox  are  small,  hard  and  resistant  to 
pressure,  but  as  a  rule  a  varicellar  eruption  with  these  charac- 
ters is  only  found  on  the  forearms,  the  leg  from  the  knee 
downwards,  the  hands,  and  the  feet,  and  if  the  whole  body 
be  inspected  when  such  an  appearance  is  found  in  these 
regions,  typical  vesicles  of  chicken-pox  will  usually  be 
apparent  elsewhere  on  the  body. 

The  eruption  of  chicken-pox  appears  first  on  the  trunk, 
and  is  most  profuse  in  that  region,  while  the  small-pox  rash 
appears  first  on  the  forehead,  wrists,  hands,  face,  legs  and 
feet,  and  is  always  more  profuse  in  these  regions,  while  it  is 
scanty  on  the  trunk,  where  it  appears  last. 

Atypical  forms  of  the  chicken-pox  eruption  are  more 
commonly  met  with  in  adults  than  in  children,  and  it  is  in 
such  cases  that  any  real  difficulty  in  the  differentiation 
between  small-pox  and  chicken-pox  will  arise.  In  differen- 
tiating small-pox  from  chicken-pox,  one  is  natiirally 
influenced  to  some  considerable  degree  by  the  date  and  degree 
of  vaccination.  If  a  doubtful  eruption  appears  in  childhood, 
say  before  the  age  of  seven  or  eight  and  the  child  has  been 
A^accinated,  even  inefficiently,  the  chances  are  largely  in 
favour  of  the  eruption  being  chicken-pox,  and  not  small-pox. 
If  in  an  adult  there  is  evidence  of  good  infantile  vaccination, 
and  the  patient  has,  in  addition,  been  successfully  re- vac- 
cinated, the  evidence  is  similarly  in  favour  of  its  being 
chicken-pox.     If,  however,  the  eruption  appears  in  a  child. 


298  Chapter  XT  111. 

even  as  young  as  from  seven  to  ten  years  of  ago,  who  shows 
evidence  of  only  very  slight  and  inefficient  vaccination,  it 
is  to  be  reinenibered  that  the  eruption  may  he  small-pox. 
Still  greater  is  the  possibility  of  the  disease  being  small-pox 
if  the  eruption  appears  in  an  adult  who  has  only  been  vac- 
cinated in  infancy,  especially  if  the  vaccination  has  evidently 
been  slight. 

Other  vesicular  eruptions  M-hich  may  be  mistaken  for 
small-pox  are  pempliigus  with  a  profuse  eruption,  where  the 
bulla-  are  small,  and  a  vesicular  syphilide.  In  these 
cases  the  eruption  should  present  no  difficulty  to  the  experi- 
enced physician. 

In  true  peviiihigus,  even  where  the  bullsp  are  small  and 
Aery  numerous,  they  are  so  much  larger  and  so  much  more 
flaccid  even  than  the  vesicle  of  chicken-pox  that  they  are 
little  likely  to  be  mistaken  for  the  small,  compact  and  firm 
vesicle  of  A'^ariola. 

A  'vesicular  syphilide,  however,  may  show  small,  closely- 
set,  firmish  vesicles,  with  a  distribution  on  the  face  and  fore- 
arms, that  may  be  very  like  the  eruption  of  true  small-pox. 
It  is  to  be  remarked,  however,  that  the  rash,  which  may  be 
profuse  in  certain  areas,  like  those  mentioned  above,  is 
irregular  and  patchy  in  distribution,  while  in  a  case  of  true 
small-pox  the  vesicles  may  be  scanty,  but  they  are  distributed 
with  some  regard  to  the  usual  distribution  of  the  rash,  and 
they  are  rarely  very  profuse  in  one  region,  while  entirely 
absent  in  another.  In  the  case  of  a  vesicular  syphilide  the 
forearms  may  be  closely  studded  with  an  eruption  that  is 
almost  confluent,  while  large  areas  of  the  trunk,  limbs  and 
face  may  be  entirely  free  from  eruption.  The  irregular 
character  of  this  eruption,  combined  with  the  history  of 
previous  venereal  infection  or  the  evidence  of  some  genit-al 
sore,  usually  places  the  diagnosis  beyond  question.  In  certain 
cases,  however,  the  test  of  vaccination  must  be  applied  before 
one  is  certain  of  the  true  nature  of  the  disease. 

It  is  not  uncommon  during  a  small-pox  epidemic  for 
the  physician  to  be  asked  to  see  cases  which  are  suspected  of 
being  small-pox,  in  which  there  is  a  definite  pustular  erup- 
tion,   most  profuse,    perhaps,   upon   the    forehead,     the    face 


Small-'pox.  29fi 

generally,  and  the  neck,  which  presents  certain  of  the 
features  of  the  eruption  of  «maIl-pox.  Upon  close  examina- 
tion, however,  these  pustules  are  found  to  be  very  mucli  more 
raised  than  tiie  ordinary  pustule  of  small-pox.  There  is 
little  swelling  of  the  surrounding  parts,  although  the  base  of 
the  pustule  may  be  deeply  reddened,  and  even  the  closest 
questioning  fails  to  educe  the  history  of  a  definite  period  of 
invasion,  and  the  patient  cannot  be  definite  that  the  eruption 
has  ever  passed  through  a  vesicular  stage.  These  pustular 
eruptions  are  due  to  acne,  or  may  be  forms  of  ranlt  followin;j 
on  the  taking  of  the  bromides  or  iodide  of  j^otassium.  If  the 
patient  is  found  to  have  been  taking  bromides  or  iodide  of 
potassium,  the  case  is  clear,  and  the  presence  of  blackheads 
and  old  scars  will  be  sufficient  to  establish  the  diagnosis  of  acne. 
Treatment. — All  patients  suffering  from  small-pox 
must  be  kept  in  bed  during  the  febrile  stages  of  the  disease. 
During  the  i^apular  stage  of  the  eruption  pain  and  irritation 
may  be  relieved  by  sponging  with  tepid  water  or  a  tepid  solu- 
tion of  2  per  cent,  carbolic  acid.  Ichthyol,  applied  to  the 
face  or  to  any  other  part  where  the  eruption  is  profuse, 
appears  to  relieve  pain  in  a  certain  number  of  cases.  Oil, 
either  plain  olive  oil,  carron  oil,  or  carbolised  olive  oil,  is 
also  used  as  an  application  to  relieve  the  discomfort  and  irri- 
tation during  this  stage  of  the  eruption.  During  the  vesicular 
and  pustular  stages,  ichthyol  or  oil  may  be  applied  to  the 
skin,  but  oily  applications  are  often  prone  to  cause  irritation, 
and  antiseptic  powders,  such  as  boric  acid,  either  alone  or 
with  starch,  are  possibh'^  better,  although  they  have  the 
disadvantage  of  making  the  crust  firmer  and  less  easy  to 
detach  from  the  skin,  thus  rather  favouring  ulceration.  A 
salicylic  cream  makes  a  pleasant  dressing  in  the  vesicular  and 
pustular  stages  of  the  disease,  the  ingredients  being  4  parts 
of  sodium  salicylate  to  100  parts  of  ordinary  cold  cream. 
Should  the  skin  be  broken  in  the  vesicular  and  pustular 
stages,  it  will  be  found  necessary  to  dress  the  parts  with  a 
simple  moist  antiseptic  dressing.  If  the  eruption  promises 
to  be  profuse  on  the  scalp,  the  hair  should  be  cut  as  close  as 
possible.  This  makes  it  easier  to  deal  with  the  eruption  in 
the  pustular  and  crusting  stages. 


300  Chapter   XV 11 1. 

In  confluent  and  semi-confiueiit  cases,  particularly  where 
the  patient  is  delirious,  it  is  necessarj'-  to  muffle  his  hands  in 
cotton  wool  to  prevent  him,  as  far  as  possible,  from  breaking 
the  vesicles  or  pustules,  thus  avoiding  the  formation  of  large 
raw  areas. 

The  handling  of  a  small-pox  patient  is  a  difficult  matter. 
Even  with  the  greatest  care  the  epidermis  is  apt  to  be  torn, 
especially  if  the  patient  is  delirious  and  struggles. 

It  is  of  the  utmost  importance  that  a  patient  who  is 
suffering  from  a  severe  attack  should  be  made  to  sleep,  and 
the  safest  hypnotic  to  use  in  small-pox  is  undoubtedly^  opium. 
Chloral  and  the  coal-tar  derivatives  have  a  disagreeably 
depressing  effect  upon  the  heart,  and  as  cardiac  failure  is  the 
chief  danger  in  small-pox  they  are  better  avoided.  Perhaps 
the  best  form  of  opium  to  use  is  the  liquor  opii  sedativus  of 
Battley.  This  should  be  given  in  15  or  20  minim  doses,  and 
repeated  every  hour  until  sleep  is  obtained,  or  60  to  90 
minims  have  been  given.  This  dosage  may  seem  excessive, 
but  the  small-pox  patient  is  curiouslj''  tolerant  of  the  drug, 
and  where  the  administration  is  confined  within  these  limits 
there  is  little  fear  of  any  bad  result.  Alcohol,  in  the  form 
of  whisky  or  brandy,  in  doses  of  3  ii- — "3  ^^-'  ''^^J  ^^  com- 
bined with  the  opium  with  advantage.  For  obvious  reasons, 
save  in  cases  in  which  the  eruption  is  discrete,  the  use  of  the 
hypodermic  syringe  is  not  to  be  advised. 

As  in  all  other  acute  fevers,  it  is  not  in  general  a  good 
practice  to  reduce  the  pyrexia  by  means  of  antipyretic  drugs 
on  account  of  tlie  danger  of  cardiac  failure,  which  is  always 
present  after  their  use.  The  one  exception,  perhaps,  to  this 
rule  is  quinine,  which  is  sometimes  of  service  in  5  or  10  gr. 
doses  in  lowering  temperature  and  lessening  headache. 

In  the  early  stages  of  the  eruption  sponging  with  tepid 
water  may  reduce  the  temperature  sufficiently  to  bring  relief 
to  the  patient's  symptoms.  The  cold  pack  is  not  to  be 
recommended. 

If  there  is  much  vomiting  during  the  initial  stages,  a 
little  morphine  will  usually  stop  it. 

Constipation  may  be  relieved  by  small  doses  of  calomel 
followed  by  mild  saline  aperients,  or  cascara  sagrada  may  be 


Small-'poA-.  301 

given,  or,  indeed,  any  aperient  that  is  pleasixnt  in  aflion,  and 
not  too  severe. 

If  much  diarrhoea  is  present,  Dover's  powder  iirid 
calomel  should  be  given,  and  the  lower  bowel  washed  out 
carefully  with   sterilised  water  once  or  twice  a   day. 

Where  there  is  some  degree  of  cardiac  failure,  alcoliol 
in  the  form  of  whisky  or  brandy  may  be  given,  in  doses  of 
3ii- — 3i^-5  ^0  be  repeated  every  two  to  four  hours.  Strychnine 
is  sometimes  useful,  and  where  the  heart's  action  is  rapid  and 
irregular  the  tincture  of  digitalis  may  be  given  with  advan- 
tage, in  doses  of  10  minims  every  four  hours  while  the 
patient  is  awake.  Adrenalin  has  been  found  useful  by  many 
physicians  where  the  blood  pressure  is  very  low  and  there  is 
a  threatening  of  collapse.  Ammonium  carbonate  is  a  good 
diffusable  stimulant  where  there  is  any  sign  of  cardiac  weak- 
ness, even  where  there  is  no  bronchial  catarrh.  If  bronchial 
catarrh  be  present,  the  ammonium  carbonate  may  be  com- 
bined with  some  spirits  of  chloroform  and  camphor  water. 

In  hsemorrhagic  small-pox,  where  there  is  much  bleeding 
from  the  mucous  surfaces,  adrenalin  and  ergotin  have  been 
used,  but  most  observers  are  agreed  that  their  employment 
has  been  followed  by  no  good  result. 

It  is  of  the  greatest  importance  that  the  mouth  should 
be  kept  clean,  and  it  must  be  swabbed  out  several  times  a 
day  with  glycerine  of  borax  or  glycerine  and  boric  acid.  If 
the  mouth  is  very  foul  it  is  wise  to  spray  it,  as  in  scarlet 
fever  and  diphtheria,  with  an  aqueous  solution  of  boric  acid 
or  sodium  bi-carbonate.  If  the  patient  is  conscious  he  may 
be  able  to  wash  his  mouth  with  glycothymolin.  of  a  strength 
of  1  part  of  glycothymolin  to  5  of  water. 

Sometimes  swallowing  is  painful  and  difficult,  and  small 
pieces  of  ice  sucked  slowly  will  help  to  relieve  this.  Where 
the  difficulty  of  swallowing  is  extreme,  painting  the  fauces 
with  a  dilute  solution  of  cocaine  before  feeding  has  been 
recommended. 

As  soon  as  the  crusts  have  formed  it  is  well  to  hasten 
their  removal  by  the  application  of  warm  poultices  of  linseed 
meal  and  oil  in  all  cases  where  the  eruption  has  been  at  all 
profuse.        This  application  may  be  made  even  to  the  face. 


302  Chafer  XVJU. 

when  the  poultice  should  take  the  form  of  a  mask,  M'ith  aper- 
tures left  for  the  eyes,  nose  and  mouth.  After  the  crusts 
liave  separated,  the  skin  should  be  frequently  washed  with 
dilute  solutions  of  boric  acid,  as  it  is  of  great  importance  that 
suppuration  should  cease  as  soon  as  possible. 

From  the  beginning  of  the  illness  the  patient's  eyes 
should  receive  careful  attention.  Vaseline,  or  better  still, 
an  ointment  composed  of  4  or  5  per  cent,  protargol,  or  some 
similar  salt  of  silver,  in  lanoline,  should  be  smeared  on  the 
edges  of  the  eyelids  at  night,  to  prevent  the  lids  sticking 
together.  The  eyes  should  be  washed  frequently  during  the 
day  with  a  solution  of  boric  acid  or  bi-carbonate  of  soda.  If 
there  is  much  swelling  of  the  eyelids  and  inflammatory 
oedema  of  their  mucous  membrane,  the  mucous  membrane 
may  be  painted  several  times  in  the  day  with  a  10  per  cent, 
solution  of  silver  nitrate,  which  should  be  immediately 
neutralised  with  salt  solution.  If  keratitis  occur  the  pupils 
should  be  widely  dilated  with  atropin,  and  the  eyes  should 
be  very  frequently  irrigated  with  warm  boric  acid  solution 
or  even  sterile  water.  If  the  intra-ocular  tension  is  decidedly 
raised,  it  is  well  to  perform  paracentesis,  which  may  be 
repeated  more  than  once  should  occasion  arise.  The  addition 
of  opium  to  the  eye-wash  in  the  form  of  the  liquor  opii 
sedativus  is  often  of  great  comfort  to  the  patient.  In  cases 
of  keratitis  where  there  is  little  sign  of  conjunctival  reaction 
warm  fomentations  should  be  applied  over  the  eyes,  and  re- 
newed every  hour  or  two.  Should  panophthalmitis  occur, 
it  is  Avell  to  lay  the  eyeball  open  from  side  to  side,  and  let 
the  discharge  escape  freely.  Small  ulcers  of  the  cornea  will 
probably  yield  to  a  yellow  oxide  of  mercury  ointment,  com- 
bined with  a  little  atropin,  a  small  quantity  of  which  may  be 
inserted  under  the  eyelid  twice  a  day.  If  the  corneal  ulcer 
tends  to  perforate,  its  edges  may  be  cauterized  with  a  fine  wire. 

All  superficial  abscesses  should  be  opened  at  once  on 
their  formation,  and  dressed  with  ordinary  warm  moist  anti- 
septic dressings. 

Laryngitis,  when  it  does  occur,  demands  A^ery  careful 
treatment.  On  the  first  appearance  of  this  complication, 
however  slight,  it  is  well  to  put  the  patient  at  once  on  Vin. 


Small-pox.  303 

Ipecac,  and  use  the  steam  tent.  A  medicated  steam  spray- 
is  also  of  service,  and  should  he  cliarged  with  either  a  simple 
soda  solution  or  a  dilute  sohition  of  carbolic  acid.  If  cedema 
of  tlie  larynx  should  occur,  it  may  he  necessary  to  perform 
traclieotoDiy.  As  this  complication  appears  usually  in  con- 
fluent cases  the  operation  of  tracliootomy  ]nay  1)0  attended 
with  much  difficulty,  on  account  of  the  SAvelling  of  the  neck, 
and  profuse  haemorrhage  from  the  infiltrated  cellular  tissue 
may  result. 

Glossitis,  if  it  be  slight,  does  not  demand  any  particular 
interference,  beyond  the  application  of  ice  to  the  tongue. 
But  in  certain  cases  the  swelling  of  the  tongue  may  be  A^ery 
considerable,  and  may  require  incision.  The  incision  should 
be  made  about  three-quarters  of  an  inch  to  the  side  of  the 
raphe,  and  should  be  about  half  an  inch  in  depth;  if  made  at 
all,  the  incision  should  be  free. 

Cellulitis  may  occur  almost  anywhere  in  association  with 
profuse  pustulation,  and  demands  free  incision  and  frequently 
repeated  warm,   moist,    antiseptic   dressings. 

Many  artifices  have  been  recommended  for  the  yreven- 
tion  or  modification  of  jmstnlation,  but  all  applications 
having  this  object  in  view  are  practically^  useless.  The  red 
light  treatment  introduced  by  Finsen  was  also  advocated  for 
this  purpose,  but  Finsen' s  good  results  have  not  been  obtained 
by  others  wlio  have  employed  the  treatment  in  this 
country.  The  development  of  the  eruption  does  not  appear 
to  be  altered  in  any  way,  the  pitting  does  not  seem  to  be 
lessened,  and  patients  confined  in  a  room  which  is  lit  only 
by  the  red  rays,  and  from  which  all  actinic  rays  are  excluded, 
seem  to  suffer  psychically  from  this  deprivation,  and  become 
restless  and  discontented,  and  the  tendency  to  delirium  seems 
to  be  increased. 

Servm  therapy  has  been  employed  in  this  country  by 
Thomson  and  Brownlee,  with  little  result.  The  serum  used 
was  obtained  from  immunised  cables  or  heifers,  and  one  notable 
disadvantage  of  this  treatment  is  the  enormous  quantity  of 
serum  required.  It  is  reckoned  that  the  amount  of  serum 
necessary  amounts  to  about  one-fiftieth  part  of  the  body 
weight  in  adults,  and  to  about  one  twentieth  part  of  the  body 


304  (•  ha  pier   XTIII. 

weight  in  children.  It  is  said  that  this  enormous  quantity 
of  serum  produces  no,  ill-effects,  but  I  recollect  at  least  one 
case  in  which  it  seemed  that  death  followed  as  a  result  of 
this  enormous  dosage.  It  would  appear  that  to  be  efficient 
the  serum  ought  to  be  more  potent  than  any  which  have  yet 
been  employed,  and,  until  such  a  serum  is  manufactured, 
serum  therapy  does  not  offer  many  attractions.  It  is  true 
that  the  cases  in  which  it  has  been  employed  are  too  few  to 
warrant  anj  very  definite  statements  being  made,  but  at  the 
present  moment  the  disadvantages  of  the  treatment  seem  to 
outweigh  any  possible  advantage. 

Where  a  contact  with  a  definite  case  of  small-pox 
develops  definite  symptoms  of  invasion,  it  is  possible  in 
certain  cases  to  abort  the  attack,  if  the  patient  is  seen  on  the 
first  or  second  day  of  illness,  by  vaccination.  After  the 
second  day  of  illness,  it  is  useless  to  attempt  this. 

Diet. — The  diet  in  small-pox  differs  in  no  way  from 
the  diet  in  any  other  acute  infectious  fever.  During  the 
febrile  stage  the  patient  must  be  kept  on  a  diet  consisting 
entirely  of  milk,  with  barley  water  and  a  little  chicken  tea. 
It  is  possible  that  an  egg  beat  up  in  milk  may  be  tolerated 
by  patients  even  in  the  acute  stages  of  the  disease,  but 
experience  goes  to  show  that  the  digestion  of  patients  suffering 
from  small-pox  is  weak,  and  that  A'ery  little  more  than  the 
ordinary  fluid   febrile   diet  can  be  tolerated   at  all. 

Alcohol  should  not  be  used  in  anything  like  routine 
fashion,  and  should  only  be  employed  to  tide  the  patient 
over  an  emergency  of  cardiac  failure,  or,  in  larger  single 
doses,  to  induce  sleep  at  night. 

As  convalescence  becomes  established,  the  appetite  of  the 
patient  may  be  taken  as  a  perfectly  safe  guide  with  regard 
to  increasing  the  dietary.  As  fever  subsides,  light  carbohy- 
drate meals  ma}-  be  introduced  in  addition  to  the  milk;  eggs 
may  be  given,  and,  within  a  week  of  the  subsidence  of  the 
fever,  the  patient  should  in  most  cases  be  able  to  tolerate  an  or- 
dinary light  diet,  which  includes  lightly  grilled  chops,  chicken 
and  fish.      At  the  end  of  another  week,  full  diet  mtij  be  given. 

If  the  suppuration  has  been  excessive  some  advantage 
may  be  obtained  during  convalescence  by  the  addition  of  stout 


Siiiall-yox.  .'i05 

ta  tke  dietary,  but  whisky  or  Imiiidy,  oj'  ;uiy  oHk!);  form  of 
alcohol,  is  no  imore  necessary  during  convalescence  from 
sniall-pox  than  during-  convalescence  from,  any  other  acute 
fever. 

In  severe  confluent  cases  the  condition  of  the  mouth  may 
make  any  dietaiy  other  than  fluid  impossible  for  even  a  week 
or  ten  days  after  the  subsidence  of  the  secondary  fever. 

Epidemiology.  —  Small-pox  maj^  arise  in  this  country  at 
any  time  of  the  year,  seeing  that  it  is  a  disease  that 
is  always  introduced  from  outside.  But  experience 
shows  that  an  epidemic  which  begins  in  spring  or  early 
summer  is  usually  of  smaller  extent  than  one  which  begins 
in  autumn  or  winter.  This  may  be  accounted  for  by  the  fact 
that  small-pox  in  this  country  arises  invariably  among  the 
poorer  classes,  where  overcrowding  is  the  rule,  and,  while 
in  summer  windows  are  apt  to  be  open  and  the  people  spend 
much  of  their  time  out  of  doors,  in  winter  they  naturally  tend 
to  herd  together  for  warmth,  and  more  opportunity  is  thus 
given  for  the  spread  of  the  disease. 

Infection  is  usually  by  direct  contact,  but  it  may  be 
spread  also  by  fomites,  notably,  by  infected  clothing.  The 
aerial  convection  of  small -pox  is  a  matter  open  to  discussion, 
but  it  seems  possible  that  it  may  occur,  and  it  is  a  potent 
argument  in  favour  of  the  proper  isolation,  not  only  of 
small-pox  patients,  but  of  small-pox  hospitals. 

The  period  of  infectivity  of  small-pox  lasts  until  the 
last  crust  has  separated  from  the  skin,  and  until  the  last 
core  has  been  removed  from  the  hands  and  feet.  The  separa- 
tion of  the  crusts  is  usually  complete  in  a  moderate  case  of 
small-pox  in  about  four  weeks,  and,  in  a  very  mild  case,  in 
some  three  weeks.  But  it  is  found  in  an  epidemic  that 
six  or  eight  weeks  is  the  ordinary:-  period  during  which  the 
patient  must  be  kept  isolated.  In  very  seA^ere  cases,  tlie 
crusts  may  not  be  completely  gone  until  ten  weeks  or  three 
months  have  elapsed. 

The  death-rate  of  small-pox  varies  very  much  according 
to  the  nature  of  the  attack,  and  also  with  the  age  of  the 
patient  and  the  efficiency  of  the  vaccination.  In  unvac- 
icinated  cases  the  younger  the  patient  the  higher  is  the  death- 


306  Chayter   XVIII. 

rate,  up  to  the  age  of  forty,  when  the  death-rate  again 
approaches  that  of  infancy  and  young  childhood.  In 
patients  who  have  been  vaccinated  only  in  infancy,  the 
death-rate  increases  with  age.  Thus  in  unvaccinated  patients 
tlie  most  dangerous  periods  are  under  &Ye  and  over  forty, 
while  the  least  dangerous  is  between  five  and  twenty,  and  in 
patients  who  have  been  vaccinated  only  in  infancy,  the 
mortality  is  practically  nothing  under  ten  years  of  age,  very 
slight  between  ten  and  twenty-,  and  thereafter  increases 
steadily  with  age. 

Small-pox  hardly  ever  occurs  in  people  who  have  been 
even  once  successfully  re-vaccinated,  and  then  the  disease  is 
usually  of  a  very  benign  character.  If  a  patient  vaccinated 
only  in  infancy  shows  an  efficient  vaccination  as  estimated 
by  the  superficial  area  of  the  marks,  the  chances  are  that  his 
attack  of  small-pox  will  be  much  less  severe  than  an  attack 
appearing  in  a  person  who  shows  an  inefficient  vaccination 
as  estimated  also  by  the  superficial  area.  There  is  no  doubt 
that  efficient  vaccination,  even  if  performed  only  in  child- 
hood, does  modify  very  considerably  the  mortality  rate  of 
small-pox  as  compared  with  the  mortality  rate  of  the  disease 
when  it  occurs  among  unvaccinated  people. 

In  estimating  the  efficiency  of  vaccination  as  indicated 
by  the  marks,  one  has  to  take  into  account  the  appearance  of 
the  scar  as  well  as  its  extent.  Well-marked  foveation  is  a 
valuable  index  to  efficient  vaccination,  and  a  well-foveated  scar 
is  reckoned  to  be  evidence  of  much  greater  efficiency  than  a  scar 
of  similar  superficial  area  which  shows  only  a  small  amount 
of  foveation  and  a  large  amount  of  ordinary  smooth  scar  surface. 

Second  attacks  of  small-pox  do  occur,  but  are  very  rare, 
and  the  second  attack  is  always  benign,  and  usually  quite 
definitely  varioloid  in  character. 

Home  Prophylaxis. — In  this  country  cases  of  small- 
pox are  not  permitted  to  be  nursed  at  home,  on  account 
of  the  great  danger  that  one  case  of  small-pox  is  to  a  com- 
munity if  permitted  to  remain  at  home  and  form  a  definite 
nucleus  for  the  spread  of  the  disease. 

Public  Health  Administration.  —  All  patients  suffering 
from     small-pox     must     be     immediately     removed     to     an 


Small-poa;.  '{07 

isolation  hospital.  Tlio  contacts  must  be  isolated,  and 
observed  twice  a  day.  All  articles  of  clothing',  bedding  and 
furniture  that  have  been  in  contact  with  a  patient  suiferinj^ 
from  small-pox  must  be  suitably  disinfected,  or,  if  this  is 
impossible  from  the  nature  of  the  article,  must  be  destroyed. 
The  house  in  which  a  small-pox  case  has  occurred  must  be 
thoroughly  disinfected  by  lime  washing  and  by  the  use  of  for- 
malin and  sulphur,  and  walls  must  be  stripped  and  repainted 
or  papered.  Any  insanitary  surroundings  must  be  corrected, 
back-courts  cleaned,  ash-pits  and  ash-bins  disinfected,  and 
the  neighbourhood  must  be  carefully  investigated  for  other 
cases. 

The  Public  Health  Authorities  should  place  a  skilled 
staff  at  the  disposal  of  the  practitioners  of  the  neighbourhood 
for  the  immediate  examination  of  any  doubtful  cases,  so  that 
no  case  may  be  missed.  One  mild  unrecognised  case  is  of 
more  danger  to  the  community  than  twenty  severe  cases  which 
are  recognised  early  and  removed  to  hospital.  All  contacts 
should  be  immediately  vaccinated,  and  vaccination  should  be 
urged  upon  the  whole  of  the  community  in  which  small-pox 
has  occurred. 

Vaccination. — The  trend  of  our  legislation  at  the 
present  moment  would  seem  to  indicate  that  the  belief  in 
vaccination  has  somewhat  waned.  Loopholes  are  given  to  the 
conscientious  objector  to  a  degree  that  makes  one  extremely 
apprehensive  of  the  character  and  extent  of  the  next  great 
epidemic  of  small-pox.  The  percentage  of  unvaccinated 
children  in  large  urban  communities  has  increased  enor- 
mously during  the  past  ten  years,  and  in  this  country  small- 
pox has  open  to  it  to-day  a  field  of  attack  larger  than  has 
been  afforded  it  for  a  generation  or  two.  It  cannot  be  denied 
by  those  who  have  had  any  experience  of  small-pox  epidemics 
that  the  greatest  and  the  most  powerful  weapon  which  we 
have  at  our  disposal  for  the  prevention  of  small-pox  is  vac- 
cination, and  yet  successive  Governments  have  deliberately 
made  evasion  of  the  vaccination  laws  more  and  more  possible. 
and  have  even  modified  these  laws  themselves.  It  is  difficult  to 
know  what  attitude  the  physician  should  adopt  under  these 
circumstances.     It  is  possible  that  this  country  may  be  capable 


308  Chapter  XVIII. 

of  learning"  the  lesson  only  by  experience,  and  that  only 
a  large  and  severe  epidemic  of  small-pox  will  convince  a 
people  who,  fortunately  for  tliemselves,  have  never  seen  the 
effects  of  practically  unmodified  small-pox  on  a  community, 
of  the  risk  that  they  are  permitting  themselves  and  their 
powerless  children  to  run.  The  arguments  of  the  anti-vac- 
cinator  will  doubtless  have  little  effect  before  the  ravages  of 
such  an  epidemic,  but  it  seems  wrong  that  legislation  should 
be  capable  of  influence  by  a  handful  of  ignorant  faddists, 
when  the  whole  weight  of  medical  opinion  is  against  their 
views. 

In  the  days  in  which  vaccination  was  done  by  the  "arm- 
to-arm"  method  it  is  probable  that  contagious  diseases  were 
sometimes  conveyed  from  an  unhealthy  to  a  healthy  child, 
and  such  results  were  quite  enough  to  give  reasonable  ground 
for  alarm  if  such  occurrences  happened  to  be  at  all  frequent. 
But  the  introduction  of  vaccination  directly  from  the  calf 
has  removed  all  such  risk,  and  there  is  now  no  room  for  sucli 
arguments  against  vaccination. 

In  pre-antiseptic  days,  too,  there  is  no  doubt  that 
unnecessary  suppuration  and  cellulitis  sometimes  followed 
on  the  operation  of  vaccination,  and  in  careless  hands  at  the 
present  da}^,  vaccination  even  with  carefully-prepared  calf 
lymph  may  be  attended  by  considerable  risk.  But  if  tlie 
operation  be  performed  with  due  consideration  of  asepsis,  if, 
in  other  words,  the  operation  of  vaccination  be  performed 
with  all  the  precautions  necessary  for  any  other  surgical 
operation,  infection  of  the  wound  by  pyogenic  organisms 
would  be  impossible.  Calf  lymph,  as  at  present  prepared,  is, 
as  far  as  pyogenic  organisms  are  concerned,  a  sterile  fluid, 
and  if  the  practitioner  takes  ordinary  precautions  no  suppura- 
tion should  result.  But  it  is  necessary  before  A^accination  to 
clean  the  patient's  arm  thoroughly  with  soap  and  water  and 
methylated  spirits,  and  the  needle  or  other  instrument  used 
for  making  the  inoculation  should  be  either  boiled  or  care- 
fully sterilised  by  heat  before  vaccination  is  done.  No  blood 
should  be  drawn  during  the  operation.  For  the  success  of 
vaccination  it  is  sufficient  to  drop  the  lymph  on  the  arm,  a  ad 
'Carefully  scrape   off  the   epidermis.     There  is  no   advantage, 


Small-pox.  309 

but  rather  the  reverse,  iu  injuring-  tlic  true  skin.  The  arm 
should  be  allowed  to  dry  in  the  air,  and  the  scarified  part 
should  afterwards  be  covered  by  a  pad  of  aseptic  wool,  after 
being  dusted  with  an  antiseptic  powder.  A  mixture  of  equal 
parts  of  boric  acid,  starch  and  lycopodium  makes  a  very  useful 
application  for  this  purpose.  The  pad  of  cotton  wool  may 
be  renewed  from  time  to  time  as  necessity  arises,  and  it  may 
be  kept  in  place  by  a  bandage  or  strips  of  plaster.  The  much 
advertised  shields  are  of  no  use,  but  are  rather  a  disadvan- 
tage, since  they  tend,  on  becoming  displaced,  to  rupture  the 
newly-formed  vesicles. 

It  is  always  well  to  impress  upon  the  patient  who  is  being 
A^accinated,  if  he  be  old  enough  to  understand,  or  upon  the 
parents  of  infants,  that  the  patient  may  suffer  some  discom- 
fort after  the  operation,  and  that  during  the  time  the 
vesicles  are  maturing  the  bowels  should  be  freely  moved,  and 
the  diet  should  be  of  a  light  character.  Adults  should  be 
forbidden  to  take  alcohol  during  this  time,  and  warned  care- 
fully that  should  they  transgress  this  rule  they  may  suffer 
from  severe  inflammation  of  the  arm.  Tlie  only  really  bad 
arms  which  I  have  seen  resulting  from  vaccination  have  been 
in  patients  who  were  naturally  very  dirty  in  their  habits,  or 
who  were  habitually  intemperate. 

As  a  necessary  precaution  against  pyogenic  infection  of 
the  scarified  part,  no  practitioner  should  vaccinate  a  child 
(except  in  the  infected  areas  of  a  community  during  an 
epidemic  of  small-pox)  if  there  is  any  tendency  to  acne  or 
eczema,  or  any  other  suppuration  about  the  patient.  The 
presence  of  an  eczema  capitis  is  quite  sufficient  reason  for 
delaying  vaccination,  and  the  operation  should  never  be  per- 
formed until  the  child  has  been  free  from  all  trace  of  the 
disease  for  at  least  a  week  or  ten  days. 

During  the  course  of  an  epidemic,  however,  it  will  be 
found  necessary  to  vaccinate  many  children  in  a  condition 
which  would  otherwise  delay  the  operation.  During  the 
course  of  an  epidemic  of  small-pox  I  have  had  to  vaccinate 
children  and  adults  in  all  stages  of  illness  who  were  suffering 
from  one  or  other  of  the  acute  fevers  other  than  small-pox, 


310  diaper  XV 111. 

and  in  no  instance  did  I  observe  any  evil  effects  followin}}^  on 
vaccination.  One  point,  however,  is  worthy  of  note,  namely, 
that  jDatients  suffering  from  measles  were  curiously  insus- 
ceptible. It  was  only  perhaps  after  a  second  or  third  attempt 
that  vaccination  was  successful  in  such  cases. 

The  normal  course  of  the  local  effects  of  vaccination  are 
roughly  as  follows : — A  little  redness  with  some  urticarial 
swelling  usually  occurs  almost  at  once  after  the  operation, 
but  this  will  probably  subside  within  twenty-four  hours.  On 
the  third  or  fourth  day  papules  make  their  appearance,  and 
these,  after  four  or  five  more  days,  develop  into  vesicles  which 
on  close  observation  are  found  to  be  multilocular,  and  are 
filled  with  a  clear  fluid.  They  are  surrounded  by  a  red  areola 
of  greater  or  less  extent  according  to  the  susceptibility  of  the 
patient.  This  areola  may  be  represented  only  by  a  narrow 
red  line  round  the  margin  of  the  vesicles,  but,  on  the  other 
hand,  it  may  be  represented  by  a  deep  crimson  blush  extending 
for  some  inches  around  the  site  of  inoculation,  even  where  the 
vaccination  is  normal,  and  there  is  no  contamination  of  lymph 
or  skin  by  pyogenic  organisms.  On  the  ninth  or  tenth  day 
of  vaccination  the  vesicles  become  pustular,  and  are  definitely 
umbilicated.  Almost  at  once  the  centre  begins  to  dry  and  a 
scab  forms  which  grows  rapidly  outwards,  and  eventually 
covers  the  whole  site  of  the  pustules.  Somewhere  between  the 
fourteenth  and  twenty-first  day  the  scab,  if  undisturbed,  falls 
off,  leaving  behind  it  a  dusky  red  scar.  This  scar  becomes 
white  in  the  course  of  a  month  or  two,  and  foveation  of  its 
surface  becomes  very  apparent.  The  degree  of  foveation 
varies  inversely  with  the  amount  of  inflammation  surrounding 
the  vaccinated  area. 

As  the  vaccination  matures  there  is  always  a  slight  degree 
of  constitutional  reaction.  The  patient  suffers  from  a  little 
malaise,  with  possibly  some  headache.  The  temperature  may 
be  raised,  and  appetite  is  often  impaired.  The  constitutional 
symptoms  reach  their  acme  from  the  eighth  to  the  tenth  day, 
and  then,  in  the  case  of  a  normal  vaccination,  rapidly  subside. 
As  a  rule  no  further  disturbance  results,  though  in  a  certain 
number  of  cases  the  patient  may  suffer  from  a  slight  degree 
of  diarrhoea. 


Sviall-yox,  311 

Various  rashes  have  been  seen  complicating  the  normal 
course  of  vaccination.  The  commonest  of  these  are  urticarial 
rashes  of  various  kinds,  limited  areas  of  simple  erythema, 
morbilliform  rashes  about  the  joints,  and  possibly  widespread 
erythema  or  a  generalised  mor])illiform  rash.  Occasionally, 
even  after  a  healthy  vaccination,  these  urticarial  rashes  may 
take  on  an  appearance  calculated  to  give  rise  to  alarm  on 
the  part  of  the  attendants.  I  liavc  seen  one  case  in  whicli  a 
rather  widespread  urticarial  eruption  became  on  the  second 
day  of  its  appearance  a  deep  purple,  and  on  the  next  day  was 
almost  black.  There  was  no  evidence  of  suppuration  at  the 
site  of  inoculation,  the  vaccinia  running  an  absolutely  normal 
course,  but  this  particular  child  was  suffering  from  whooping- 
cough  at  the  time  when  it  had  to  be  vaccinated.  The  child 
suffered  no  constitutional  disturbance  in  connection  with 
the  appearance  of  the  rash,  the  vaccinia  ran  a  normal 
course,  the  scabs  were  separated  by  the  sixteenth  day,  the  rash 
fading  completely  about  the  same  time. 

Yaccinia  may  become  generalised  either  by  auto-inocula- 
tion or  by  direct  infection  of  other  parts  from  the  original  site 
of  inoculation.  This  is  not  a  common  condition,  but  when 
it  does  occur  it  may  give  rise  to  very  serious  disturbances,  and 
death  as  a  result  has  been  recorded  in  a  few  cases. 

Supernumerary  vesicles  round  the  site  of  inoculation  are 
met  with  not  infrequently,  and  rarely  give  rise  to  any  more 
trouble  than  that  which  might  be  expected  to  follow  on  a 
great  increase  of  the  vaccinated  surface.  If  scrupulous 
cleanliness  is  observed  in  the  treatment  of  such  cases,  it  is  not 
likely  that  any  ill  will  result. 

Urticaria]  rashes  may  appear  at  any  time  from  the  second 
to  the  tenth  day.  Generalised  vaccinia  occurs  somewhere 
about  the  end  of  the  first  week,  usually  just  as  the  pocks 
mature. 

The  numher  of  marJcs  necessary  for  efficient  vaccination 
is,  as  recommended  by  the  Local  Government  Board,  four,  and 
certainly  where  the  patients  belong  to  a  class  where  re-vaccina- 
tion is  improbable,  it  is  wise  to  adhere  to  this  recommendation. 
But  where  the  patients  belong  to  the  intelligent  and  educated 
classes,   and  are  likely  to  be  under  the  more  or  less  direct 

Y  2 


312  Chapter  AT///. 

eontiol  of  a  physician  during-  their  whole  life,  it  is  quite 
unnecessary  to  vaccinate  so  severely  in  infancy.  One  fair- 
sized  mark  will  be  found  sufficient  in  most  cases  to  protect 
the  child  for,  say,  seven  or  eight  j-ears.  At  the  end  of  this 
time  the  child  sliould  be  re-vaccinated,  and  re-vaccination 
should  be  again  done  somewhere  about  the  end  of  school  age. 
It  is  most  likely  that  a  person  who  has  been  vaccinated  in 
infanc}',  and  re-vaccinated  twice  before  the  age  of  twenty, 
will  be  reasonably  protected  against  small-pos  for  the  rest  of 
his  life,  even  if  onlj^  one  of  the  attempts  at  re-vaccination  has 
been  successful.  It  stands  to  reason,  however,  that  all  people 
who  find  themselves  near  an  epidemic  of  small-pox  should  be 
re-vaccinated  at  once,  however  successful  attempts  at  re-vac- 
cination  have   been   previously. 

Many  children  are  insusceptible  to  vaccination  on  the 
first  attempt  in  infancy,  but  no  child  should  be  finally  con- 
sidered as  insusceptible  until  three  or  four  attempts  have  been 
made  before  the  child  is  a  year  old.  A  child  who  proves 
refractory  to  a  first  or  even  to  a  second  vaccination  is  often 
successfully  vaccinated  on  the  third  attempt.  Failure  of  the 
first  vaccination  followed  by  a  successful  second  attempt  is 
extremely  common   in   practice. 

The  possible  dangers  of  vaccination,  where  good  lymph  is 
used  and  where  proper  surgical  precautions  are  taken  before 
and  during  the  operation ,  are  so  remote  that  the  general  public 
has  less  reason  to  condemn  A'accination  than  almost  any  other 
surgical  procedure,  and  under  these  conditions  it  is  extra- 
ordinary that  an  anti-vaccination  campaign  should  be  attended 
by  even  a  tithe  of  the  success  it  has  at  the  present  day.  After 
all,  vaccination  and  re-vaccination  are  the  only  sure  and 
certain  methods  at  our  disposal  just  now  for  the  eradication  of 
small-pox,  and  any  legislature  gifted  with  even  an  average 
amount  of  commonsense  should  not  only  enforce  the  vaccina- 
tion laws  as  much  as  possible,  but  should  introduce  an  addi- 
tional regulation  insisting  upon  re-vaccination  before  the  age 
of  eighteen.  If  these  precautions  were  observed  the  adminis- 
trators of  our  large  cities  would  not  need  to  suffer,  as  they  do 
now,  from  the  dread  of  a  great  small-pox  epidemic  at  no 
distant  date. 


SMALLPOX     CHARTS      N°     I      2     &    3. 


Chakt  (1)  Variola  vera — confluent  attack 
Teraporature  has  not  fallen 
secondary  fever. 

Chart  (2)     Variola  vera 


Chart  (3)     Varioloid — patient  aged  1 


dult  of  twenty-nine  years  of 

at-ed  in   infancy— recovery.      Note 

perature  between  primary  and  secondary 

nated  in  infancy.     No  secondary 


In  a  previously  unvacoinated  child  of  6ve  years  of  age. 


n  with  the  eruption  o 

mperature  as  eruptio 

ation  with  gangrene. 

A  mild  attacii  wit 


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Chapter  XIX. 

CHICKEN-POX. 

Synonym.  —  Varicella. 

German:  Die  Wasserpocken,  Varicellen. 
French :   La   Varicelle. 

Definition. —  An  infectious  disease  characterised  by- 
fever  and  the  appearance  of  a  specific  eruption,  which  is 
vesicular  in  character,  and  usually  appears  in  successive  crops. 
No  specific  micro-organism  has  been  isolated  in  this  disease. 

Incubation.  —  The  incubation  period  of  chicken-pox 
is  most  usually  fourteen  days,  but  it  may  be  as  short  as 
eleven  and  as  long  as  twenty-one  days.  Fourteen  days  is  by 
far  the  commonest  period  of  incubation. 

Rash.^ — The  rash  of  chicken-pox  usually  appears  between 
the  first  and  the  third  day  of  the  disease.  In  children  it  is 
usually  the  first  indication  of  illness.  It  may  appear  all  at 
once,  but  this  is  not  common,  except  in  those  cases  where  the 
eruption  is  A^ery  scanty.  In  the  great  majority  of  cases  suc- 
cessive crops  appear  from  day  to  day,  and  usually  there  are 
not  more  than  two  or  three,  or  at  the  most  four,  of  these  crops. 

The  rash  usually  makes  its  appearance  first  on  the  back, 
chest  and  abdomen,  then  spreading  to  the  face  and  limbs,  but 
in  a  minority  of  cases  it  has  been  seen  to  appear  first  on  the 
face  and  limbs,  afterwards  spreading  to  the  back,  chest,  and 
abdomen. 

The  eruption  consists  at  first  of  small  pale  red  papules, 
which  disappear  on  pressure.  Certain  of  them  have  even  at 
the  beginning  a  central  acuminated  appearance  at  the  point 
Avhere  the  vesicle  afterw-ards  appears.  The  papules  develop 
almost  at  once  into  vesicles  wliich  are  unilocular  and  have  a 


314  Chapter  XIX. 

very  thin  envelope.  They  are  filled  with  an  extremely  clear 
fluid,  like  water,  and  are  usually  slightly  oval  in  shape,  with, 
at  times,  an  irregular  edge.  The  vesicle  is  very  superficial 
for  the  most  part,  except  on  the  scalp,  forearms,  hands  and 
feet,  where  it  is  rather  more  deeply  set  in  the  skin,  and  may 
be  rounder,  harder,  and  smaller  in  these  situations  than  else- 
where on  the  body,  thus  closely  resembling  in  many  cases  the 
eruption  of  small-pox.  The  vesicles  are  very  easily  ruptured ; 
so  easily,  indeed,  that  they  seldom  survive  friction  and 
scratching  long  enough  to  become  definitely  purulent. 

When  the  vesicle  remains  uni'uptured,  it  becomes  puru- 
lent in  a  couple  of  days,  and  very  speedily  begins  to  dry  up, 
at  first  in  the  centre,  where  a  scab  forms  which  spreads  rapidly 
to  the  periphery.  The  crusts  are  usually  dark  in  colour,  and 
retain  more  or  less  an  oval,  or  sometimes  an  irregular,  shape. 
The  crusts  fall  off  in  from  three  or  four  days  to  a  fortnight  as 
n  rule,  but  some  crusts  may  adhere  for  three  or  four  weeks. 

The  eruption,  as  has  alread}'  been  described,  appears  in 
successive  crops,  so  that  at  the  end  of  three  or  four  days  a  few 
square  inches  of  skin,  say,  on  the  back,  may  present  all  stages 
of  the  eruption,  from  papules  to  scabs. 

Symptoms  of  Invasion. — Beyond  an  hour  or  two  of 
malaise,  and  possibly  a  little  fever,  it  is  not  common  in  the 
case  of  children  to  have  any  very  definite  period  of  invasion 
in  chicken-pox.  Indeed,  in  most  cases  the  appearance  of  the 
rash  is  the  first  indication  of  the  disease. 

Tn  adults,  however,  the  symptoms  of  invasion  may  be 
veiy  definite,  and  may  last  for  two  or  three  davs.  Headache, 
general  malaise,  high  fever,  vomiting  and  aching  in  the  body 
and  limbs  may  be  present  for  some  days  before  the  appearance 
of  the  eruption.  As  the  eruption  appears  the  symptoms  of 
invasion  subside  rapidly,  and  as  a  rule  the  discomfort  of  the 
patient  is  at  an  end. 

Clinical  Types, —  The  classical  type  of  chicken-pox  is 
til  at  in  which  the  eruption  appears  on  the  back,  chest  and 
abdomen,  afterwards  invading  the  face  and  limbs,  with  no 
period  of  invasion,  or  at  the  most  a  few  hours  of  discomfort. 

The  temperature  may  or  may  not  be  elevated.  In  many 
cases  where  the  eruption  is  the  first  sign  of  the  disease  the 


Chicken-pox.  3i5 

temperature  may  not  be  raised  until  two  or  three  rlays  after 
the  appearance  of  the  rash.  In  such  cases  the  rise  of  tem- 
perature is  coincident  with  the  suppuration  of  the  vesicles. 
The  temperature  is  only  slightly  elevated  and  falls  to  norma] 
again  in  about  a  couple  of  days.  If  the  rash  is  very  profuse 
the  temperature  may  be  raised  as  the  papules  appear,  falling 
again  as  the  vesicles  develop,  and  rising  once  more  as  the 
pustules  form.  This  type,  as  will  be  seen,  resembles  very 
closely  the  pyrexia  of  small-pox.  In  those  cases  which  have  a 
definite  period  of  invasion  the  temperature  often  rises  gradually 
from  the  first  appearance  of  the  prodromal  symptoms  until 
the  vesicles  are  fully  developed,  and  pustulation  occurs.  As 
crusting  proceeds  the  temperature  falls  by  lysis.  In  such 
cases  there  may  be  no  definite  period  of  apyrexia  separating 
the  primary  from  the  secondary  fever.  The  height  of  the 
temperature  varies  very  much.  In  many  cases  the  disease 
may  run  its  course  without  any  real  elevation  of  temperature 
at  all.  In  more  severe  cases  the  pyrexia  is  moderate,  rising, 
say,  to  100°  or  perhaps  101*-*  F.,  while  in  certain  severe  cases 
the  temperature  may  rise  to  over  104°  F.  or  even  higher  at  the 
acme  of  the  disease. 

Even  in  severe  cases  the  behaviour  of  the  rash  is  very 
much  as  has  been  already  described,  the  only  difference  being 
that  certain  of  the  pustules  lead  to  a  destruction  of  the  skin 
comparable  to  that  met  with  in  small-pox,  and  on  the  separa- 
tion of  the  crust  definite  pitting  with  a  foveated  scar  may  be 
seen.  Such  a  scar  is  usually  oval  or  of  an  irregular  outline, 
the  long  axis  of  the  oval  mark  being  as  a  rule  in  a  line  with 
the  natural  folds  of  the  skin.  It  is  not  usual  for  more  than 
a  very  few  of  these  marks  to  be  left  even  after  a  severe  attack 
of  the  disease. 

As  has  been  said  before,  chicken-pox  with  a  definite 
period  of  invasion  is  met  with  much  more  commonly  among 
adults  than  among  children,  and  chicken-pox  may  be  in  adult 
life  a  disease  of  some  severity.  Among  adults,  too,  the  distri- 
bution of  the  rash  may  be  a  little  abnormal.  It  is  among 
adults  that  a  rash  composed  of  small,  deeply-set  elements  is 
chiefly  met  with,  having  a  distribution  on  the  face  and  fore- 
arms more  profuse  than  normally.     Among  adults,   too,   and 


31 G  Chapter  XIX. 

even  among  children,  altliougli  more  rarely,  vesicles  are  some- 
times found  on  the  palms  of  the  hands  and  on  the  soles  of  the 
feet,  and  cases  of  this  kind  are  not  infrequently  confused  with 
small-pox. 

As  IS  the  case  with  all  the  acute  fevers,  chicken-pox 
may  develop  a  grave  type,  and  the  two  most  severe  forms  of 
the  disease  are  the  hcemorrhagic  and  the  gangrenous. 

The  hsemorrhagic  type  of  chicken-pox  is  extremely  rare; 
the  vesicles  are  few  in  number,  and  haemorrhages  occur  in  the 
skin  and  into  the  bases  of  the  vesicles.  It  is  said  by  those  who 
have  seen  something  of  this  type  of  the  disease  that,  although 
it  is  serious,  it  is  not  usually  fatal. 

The  gangrenous  type  of  the  disease  is  also  uncommon,  but 
is  sometimes  seen  when  chicken-pox  attacks  children  who  are 
badly  nourished,  or  who  are  suffering  from  the  effects  of  an 
attack  of  another  infectious  fever,  such  as  tuberculosis  or 
scarlet  fever.  In  this  type  of  the  disease  the  pustules  mature 
in  the  ordinary  way,  but  certain  of  them  become  infected  with 
pyogenic  organisms.  They  enlarge  considerably  beyond  the 
normal  size,  and  become  surrounded  by  a  deep,  angry,  inflam- 
matory zone.  A  thick  black  crust  forms,  and  purulent 
material  forms  beneath  it  and  oozes  from  under  its  edge.  On 
the  separation  of  the  crust  a  deep,  ugly-looking,  punched-out 
ulcer  is  left,  with  a  sloughing  base,  and  thick  unhealthy 
looking  edges,  usually  deep  red  or  purple  in  colour,  which 
may  slightly  overhang  the  base.  Such  an  ulcer  may  pene- 
trate the  whole  depth  of  the  subcutaneous  tissues,  leaving  the 
muscle  exposed.  They  vary  in  size  from  about  half  an  inch 
to  some  two  inches  in  diameter.  Their  outline  is  roughly 
circular,  but  the  edges  are  usually  somewhat  irregular. 
The  ordinary  situation  of  the  ulcers  is  on  the  abdo- 
minal wall  or  on  the  back.  Such  ulcers  are  quite  evidently 
due  to  some  cause  outside  the  specific  infection  of  chicken-pox. 
and  are  simply  the  result  of  a  local  destructive  lesion  produced 
probabl}^  by  ordinary  pyogenic  organisms  in  patients  whose 
resistance  to  infection  has  been  greatly  weakened  both  by  the 
attack  of  chicken-pox  and  by  some  antecedent  disease  which 
has  overtaxed  their  tissues.  Many  such  cases  die  of  a  slow 
septic0e7nia,   and  even   among  those  who  recover  the  process 


CUioken-'[)ox.  317 

of  repair  both  local  and  general  is  very  slow,  and  the  course 
of  the  illness  is  attended  by  much  wasting.  The  ulcers  in  a 
gangrenous  case  leave  ugly,  puckered  scars  on  healing. 

Complications.  —  There  are  practically  no  complica- 
tions which  arise  in  connection  with  an  attack  of  chicken-pox. 
Broncho-pneumonia  and  bronchial  catarrh  are  probably  acci- 
dental, if  they  do  occur,  and  laryngitis,  which  sometimes 
occurs  as  the  eruption  develops  fully,  is  very  rare.  Al])nnm) 
may  be  present  in  the  urine,  but  it  is  usually  a  transient 
symptom,  and  probably  toxic  in  origin.  Severe  laryngitis, 
associated  with  oedema  of  the  glottis,  has  been  described  as 
occurring  in  severe  cases  of  chicken-pox,  but  the  condition  is 
very  uncommon. 

Sequel3B.  —  A  certain  amount  of  cachexia  may  persist 
for  some  weeks  after  a  severe  attack  of  chicken-pox,  but  beyond 
this  the  only  sequelae  worth  mentioning  is  nej)hritis,  which 
has  been  observed  by  several  writers.  It  seems  likely  that 
the  nephritis  may,  as  in  the  case  of  scarlet  fever,  be  due  to 
the  specific  infection,  and  in  general  resembles  in  type  that 
which  complicates  scarlatina. 

Diagnosis.  — -  The  diagnosis  of  chicken-pox  is  usually 
very  easy,  particularly  if  the  patient  is  seen  early  in  the 
disease.  The  typical  vesicle,  with  its  oval  shape,  superficial 
situation,  delicate  envelope  and  watery  contents  is  very 
characteristic,  and  the  appearance  of  the  vesicles  in  successive 
crops  after  a  very  short  papular  stage  and  practically  no  period 
of  invasion,  makes  the  disease,  if  it  is  typical,  easy  of 
diagnosis. 

The  characteristic  distribution  of  the  rash  is  an  important 
aid  to  diagnosis.  In  addition  to  what  has  been  already  said 
on  this  score,  it  is  well  to  remember  that  in  chicken-pox  the 
flanks  are  usually  well  covered  with  the  eruption,  and  the 
axillae  are  frequently  invaded  b}^  the  rash. 

The  differential  diagnosis  between  chicken-pox  and  small- 
pox has  already  been  considered  at  some  length  in  the  chapter 
on  small-pox,  but  it  may  be  well  to  mention  again  some  of  the 
points  of  importance  when  such  a  differential  diagnosis  falls 
to  be  made.     If  a  patient  under  ten  years  of  age,  with  good 


318  Chapter  XIX. 

vaccination  marks,  lias  a  profuse  eruption,  it  is  almost  impos- 
sible that  tlie  condition  can  be  anything  but  chicken-pox.  A 
scanty  eruption  in  such  a  patient  might  possibly  lead  to  some 
difficulty,  but  in  chicken-pox  a  scanty  eruption  is  scarcely 
ever  preceded  by  any  notable  period  of  invasion,  whereas  in 
small-pox  the  period  of  invasion  is  usually  well  marked  and 
possibly  severe  although  the  eruption  may  afterwards  be  very 
scanty.  The  fact  that  recent  vesicles  in  chicken-pox  scarcely 
ever  show  any  umbilication  affords  another  distinction  between 
them  and  the  vesicles  of  small-pox,  which  are  usually,  even  at 
an  early  stage,  definitely  umbilicated.  The  vesicles  of  chicken- 
pox  are  very  fragile  and  easily  ruptured  by  pressure;  the 
vesicles  of  small-pox  are  firm,  and  a  considerable  amount  of 
effort  is  necessary  to  rupture  them  by  pressure  of  the  finger. 
The  eruption  of  chicken-pox  is  most  profuse  on  the  trunk  and 
abdomen,  and  the  axillae  may  be  invaded;  whereas  in  small- 
pox the  face,  forearms,  hands  and  feet  show  an  eruption 
which  is  much  more  profuse  than  on  the  trunk  and  abdomen, 
while  it  is  very  unusual  to  find  a  small-pox  vesicle  on  the 
axillae.  The  characteristic  oval  or  irregular  edge  of  the 
chicken-pox  vesicle  is  in  striking  contrast  to  the  rounded 
vesicle  of  small-pox. 

Chicken-pox  may  be  also  confused  with  impetigo  and 
herpes.  Impetigo  is  only  likely  to  be  confused  with  chicken- 
pox  in  the  crusting  stage.  The  presence  of  one  or  two  typical 
vesicles  would  place  the  diagnosis  beyond  question.  In 
impetigo  the  pustules  and  crusts  are  usually  more  profuse  on 
the  face  than  elsewhere,  but  in  certain  cases  they  may  be  suffi- 
ciently numerous  on  the  body  to  give  rise  to  some  difficulty. 
The  fact  that  the  crusts  were  oval  would  be  in  favour  of  the 
disease  being  chicken-pox,  but  where  the  chicken-pox  crust 
has  formed  and  been  removed  and  re-formed  perhaps  several 
times,  the  oval  character  is  apt  to  be  lost,  and  since  at  this 
stage  of  the  disease  it  is  not  likely  that  any  vesicles  will  be 
present,  it  is  .sometimes  quite  impossible  to  make  a  definite 
differential  diagnosis.  The  patient  must  be  isolated  on 
suspicion. 

In  the  case  of  herpes,  the  localisation  and  characteristic 
grouping  of  the  vesicular  elements  is  usually  sufficient  to  make 


Chicken-pox.  319 

a  definite  diagnosis  possible  on  a  reasonably  careful  examina- 
tion. 

Pem'phifjus  in  the  earl^^  stages,  when  the  bullae  are  small, 
may  closely  resemble  chicken-pox,  but  in  most  cases  large 
characteristic  bullae  soon  make  their  appearance  and  render 
diagnosis  an  easy  matter. 

Treatment. —  For  convenience  of  isolation  a  patient 
suffering  from  cliicken-pox  sliould  be  kept  in  bed  at  least  until 
the  crusts  are  completely  formed.  Beyond  keeping  the 
patient  reasonably  Avarm  and  paying  attention  to  the  bowels, 
no  special  treatment,  other  than  rest,  is  required.  If  there 
is  much  itching  of  the  skin  a  simple  dusting  powder  may  be 
used,  or  a  little  zinc  ointment.  In  gangrenous  cases  the  ulcers 
should  be  dressed  with  large,  moist,  antiseptic  dressings. 

Diet. — In  all  cases  of  chicken-pox  of  moderate  severity 
an  ordinary  light  diet  may  be  employed,  not  necessarily  fluid. 
Where  the  fever  riins  high,  however,  it  is  well  to  keep  the 
patient  on  a  fluid  dietary  until  it  has  subsided,  when  an 
ordinary  light  diet  may  be  given.  In  gangrenous  cases,  after 
the  primary  fever  has  subsided,  feeding  should  be  liberal,  and 
malt  and  iron  will  be  found  useful  in  promoting  convalescence. 
It  may  be  necessary  in  such  cases  to  give  small  quantities  of 
alcohol  should  there  be  any  sign  of  cardiac  failure. 

Epidemiology. —  Chicken-pox  is  endemic  in  most  towns, 
and  frequently  shows  an  epidemic  prevalence.  Such 
epidemic  increase  may  appear  any  time  of  the  year,  but  is 
possibly  most  common  in  the  autumn.  It  may  attack  patients 
of  any  age,  but  is  certainly  commoner  during  the  first  ten 
years  of  life  than  at  any  other  period. 

It  is  highly  infectious,  and  tlie  infection,  although 
usually  conA^eyed  directly  from  person  to  person,  can 
undoubtedly  be  carried  by  a  third  person  who  is  not  suffering 
from  the  disease,  and  can  also  be  carried  by  clothing  and  other 
infected  material.  The  infection  is  more  short-lived  than  in 
the  case  of  small-pox. 

It  is  presumed  that  the  infection,  as  in  small-pox.  is 
carried  by  the  crusts.  This  may  or  may  not  be  true,  but  it  is 
the  usual  plan  to  consider  the  patient  infective  until  all  the 
crusts  have  separated. 


320  Chaiiter  XIX. 

Ueatli  never  results  in  uncomplicated  cases  of  chicken- 
pox,  and  it  is  only  the  gangrenous  cases  which  are  at  all 
likely  to  be  fatal.  As  the  gangrenous  cases  occur  only  in 
marasmic  children  and  in  those  who  are  convalescing  from  a 
severe  illness,  such  as  the  septic  type  of  scarlet  fever,  or  are 
the  subject  of  tubercle,  it  is  always  a  difficult  matter  to  say  to 
what  degree  the  antecedent  disease  has  influenced  the  mortality 
in  such  cases. 

Second  attacks  of  chicken-pox  do  occur,  but  are  certainly 
very  rare. 

Home  Prophylaxis.  —  The  patient  should  be  isolated 
from  other  members  of  the  household,  and  should  be 
under  the  care  of  a  separate  attendant  until  the  last  crust  has 
separated  from  the  skin.  All  articles  which  are  in  the  room 
or  have  been  at  any  time  in  contact  with  the  patient  must  be 
carefully  disinfected  before  being  washed,  and  the  attendant 
should  wear  an  overall  and  keep  it  in  the  room,  taking  it  off 
before  going  out,  and  putting  it  on  when  she  re-enters  the  sick- 
room. 

Public  Health  Administration.  —  The  room  in  which  a 
case  of  chicken-pox  has  been  nursed  must  be  carefully 
disinfected  in  the  ordinary  way  before  the  house  can  be  con- 
sidered free  from  infection. 

While  hospital  accommodation  is  not  usually  provided  for 
cases  of  chicken-pox,  it  may  be  found  necessarj^  where  the 
disease  has  broken  out  in  a  very  poor  locality  to  remove 
children  to  hospital  for  their  own  sakes  rather  than  for  the 
sake  of  the  community.  All  local  authorities  should  be  pre- 
pared  to   afford   accommodation   for   this   purpose. 

All  children  who  have  been  exposed  to  the  infection  of 
chicken-pox  should  be  quarantined  for  twenty-one  days,  or  to 
be  perfectly  safe,  for  twenty-five  days,  before  being  allowed 
to  go  to  school. 

Seeing  that  the  disease  is  so  benign,  any  systematic  disin- 
fection of  areas  by  the  local  authorities  is  quite  unnecessary. 
Chicken-pox,  as  far  as  the  community  is  concerned,  is  only 
important  on  account  of  its  resemblance  to  the  gi^aver  disease, 
small-pox. 


(   321   ) 


Chapteh   XX. 

TYPHUS. 

Synonyms. —  Spotted  fever;  gaol  fever. 
German  :  Exanthematischer  Typhus ;  Fleckfieber. 
French :  Typhus  exanthematique. 

Definition. — An  acute  specific  fever,  highly  infec- 
tious, characterised  by  a  measly  and  petechial  eruption, 
marked  mental  symptoms  and  great  prostration,  running  a 
course  of  about  fourteen  days.  No  specific  micro-organism 
has  been  isolated  in  this  disease. 

Incubation  Period.— The  incubation  period  of  typhus 
fever  is  about  twelve  days.  In  a  few  rare  cases  it  has 
been  recorded  to  have  been  as  short  as  four  or  five  days,  and 
in  others  as  long  as  three  weeks.  For  purposes  of 
isolation  and  the  detection  of  the  origin  of  an  epidemic,  it  is 
the  practice  in  this  country  to  consider  fourteen  days  as  the 
usual  incubation  period. 

Rash. — The  eruption  of  typhus  appears  first  on  the 
fourth  and  fifth  day  of  the  disease,  and  is,  at  this  stage,  defi- 
nitely morbilliform  in  character.  In  consists  of  spots  or 
maculse  which  are  at  first  slightly  elevated  above  the  skin, 
and  which  disappear  on  pressure.  These  spots  make  their 
appearance  first  of  all  about  the  margin  of  the  axilla  and  on 
the  wrist,  then  the  flanks  are  invaded,  and  afterwards  the 
chest,  back,  shoulders,  thighs  and  arms. 

The  spots  are  irregular  in  size  and  outline.  They  are  of 
a  pale  dusky  red  in  colour,  and  do  not  present  a  very  definite 
margin,  but  tend  to  fade  gradually  into  the  normal  skin  which 
surrounds  them.     In  addition  to  these  definitely  elevated  spots 


322  Chapter  XX. 

a  dusk}'  subcuticular  mottling  is  apparent,  occupying,  roughly, 
tlie  same  areas  as  the  morbilliform  elements  of  the  rash.  These 
slightly  elevated  spots  and  the  subcuticular  mottling  together 
constitute  the  "  mulberry  eruption  "  described  by  Sir  William 
Jenner.  AVhen  this  rash  is  present  in  its  classical  form  it  is 
extremely  characteristic,  but  in  many  cases  the  morbilliform 
elements  are  almost  entirely  wanting,  and  only  the  subcuti- 
cular mottling  is  apparent. 

Somewhere  about  the  end  of  the  first  week,  between  the 
eighth  and  ninth  day  of  the  disease,  the  maculae  become  dark 
in  colour,  and  tend  to  be  "  fixed."  In  addition  to  this  change 
of  appearance  in  the  original  eruption,  petechial  spots  appear 
either  in  the  centre  of  the  irregular  blotches  already  men- 
tioned, or,  as  occurs  in  many  cases,  on  the  flanks,  the  axillary 
margins,  the  chest,  the  arms,  the  back,  and  the  thighs,  quite 
independently  of  any  previously  existing  rash.  In  the 
strictly  classical  type  of  the  disease,  where  the  mulberry  rash 
has  been  well  marked,  the  petechise  usually  occupy  a  position 
more  or  less  corresponding  to  the  central  portion  of  the  mor- 
billiform blotches.  In  the  more  modified  typhus,  however, 
with  which  we  are  perhaps  more  familiar  nowadays,  it  is 
common  to  have  practically  no  morbilliform  rash  at  all ;  the 
mulberry  eruption  is  expressed  only  by  a  profuse  subcuticular 
mottling,  and  the  petechise  appear  as  described  above,  without 
any  very  definite  association  with  the  pre-existing  rash. 

If  the  petechial  elements  of  the  rash  are  not  very  abun- 
dant, the  eruption  begins  to  fade  about  the  tenth  day,  but 
some  staining  of  the  skin  persists  as  a  rule  for  some  days  at 
least  after  the  crisis.  If,  however,  the  petechial  character  of 
the  rash  be  well  marked,  staining  will  persist  for  a  much 
longer  period. 

Period  of  Invasion. — The  invasion  of  typhus  is,  in  the 
large  majority  of  cases,  like  that  of  pneumonia,  sudden 
and  severe.  The  patient  is  seized  with  headache,  nausea,  and 
vomiting,  and  a  marked  sensation  of  cold,  amounting  in  the 
majority  of  cases  to  actual  rigor.  Pain  in  the  back  and  limbs 
and  tinnitus  aurium  are  very  frequently  present.  So  sudden 
is  the  onset  of  the  symptoms  of  invasion  that  the  patient  can 
often    tell    the    actual    hour    at    which    he    took    ill.        In 


TypJius.  323 

most  cases  the  patient  feels  perfectly  well  before  the 
appearance  of  these  symptoms,  but  sometimes  the  actual  onset 
of  the  disease  is  preceded  by  a  few  days  of  general  malaise, 
with  vertigo,  headache  and  anorexia. 

After  the  onset  of  the  attack  the  patient's  sleep  becomes 
disturbed  and  broken  by  dreams.  Actual  sleeplessness  is 
quite  common.  Appetite  is  lost,  and  the  mental  faculties  are 
dulled,  so  that  the  patient  is  stupid,  answers  questions  inco- 
herently, and  during  the  snatches  of  sleep  wliich  he  obtains 
tends  to  talk  in  a  rambling  way.  There  is,  however,  at  this 
stage  of  the  disease,  no  tendency  to  violent  delirium.  The 
patient  suffers  from  loss  of  appetite,  constipation,  and  very 
frequently  from  persistent  and  troublesome  nausea,  although 
vomiting  is  not  usual.  The  tongue  is  coated  with  a  white 
fur,  the  pulse  is  rapid  and  full,  and  the  frequency  of  the 
respiration  is  greatly  increased.  The  face  at  first  is  dusky 
and  congested  looking,  the  eyes  are  injected  and  rather  watery; 
the  expression  at  first  indicates  mere  weariness,  but  at  the 
end  of  the  first  day  or  so  becomes  listless,  heavy,  and  rather 
sullen.  As  the  period  of  invasion  advances,  the  expression 
of  the  face  grows  vacant  and  indicative  of  mental  confusion. 
Sometimes,  as  the  time  for  the  appearance  of  the  eruption 
approaches,  the  expression  becomes  wild  and  anxious,  and  the 
whole  aspect  of  the  patient  betokens  the  onset  of  severe  nervous 
disturbance.  As  the  pre-eruptive  stage  of  the  disease  comes 
to  an  end,  the  face  grows  duskier  in  colour,  and,  although 
still  flushed  and  congested  looking,  presents  the  "  earthy  hue  " 
which  is  so  typical  of  the  facies  of  typhus. 

Clinical  Types. — After  the  period  of  invasion  is  over, 
and  the  disease  is  thoroughly  established,  that  is,  about 
the  fourth  or  fifth  day  of  illness,  the  rash  appears,  and  the 
patient  begins  to  show  signs  of  great  nervous  excitement.  He 
grows  restless,  wakefulness  becomes  even  more  marked,  and 
delirium  sets  in.  As  is  common  in  all  fevers,  with  the  onset 
of  delirium  headache  disappears. 

Between  the  fourth  and  fifth  dav  the  tongue  becomes  dry 
and  brown,  sordes  collect  on  the  teeth,  lips  and  gums,  and  the 
breath  has  an  extremely  offensive  smell.  The  amount  of 
sordes  usually  varies  directly  with  the  severity  of  the  attack. 


324  Chapter  XX. 

Towards  the  end  of  tlie  first  week  delirium  usuallj^  becomes 
more  marked.  It  is  sometimes  noisy  and  maniacal,  while  in 
other  cases  it  closely  resembles  delirium  tremens,  and  is  accom- 
panied by  great  muscular  restlessness  and  tremor,  and  the 
patient  may  talk  incoherently  and  incessantly.  In  certain 
cases,  again,  the  delirium  is  almost  from  the  beginning  of  a 
low  muttering  character.  Restlessness  and  excitement  are  most 
marked  as  night  comes  on,  and  the  patient  tends  to  be  more 
prostrated  in  the  luornings.  Delirium,  of  one  kind  or  another, 
usually  persists  until  the  crisis  of  the  disease,  or  until  death 
occurs. 

Somewhere  about  the  tenth  day  the  more  active  delirium 
and  restlessness  are  replaced  by  a  state  of  profound  mental  and 
physical  prostration.  It  is  during  this  period,  which  lasts 
until  the  time  of  the  crisis,  that  the  most  dangerous  stage  of 
the  disease  is  entered  upon.  The  patient  lies  on  his  back, 
sunk  in  the  bed.  He  is  quite  careless  of  his  surroundings, 
and  mutters  incoherently  to  himself,  and  the  expression  of 
his  face  is  dull  and  apathetic.  The  eyes  are  injected,  and  the 
pupils  are  usually  extremely  contracted.  The  tongue  is  dry, 
shrivelled,  and  brown,  sometimes  almost  black.  There  is 
marked  tremor  of  the  muscles,  and  subsuJtus  tendinum,  with 
spasmodic  twitching  of  all  the  muscles  particularly  of  the 
face,  and  picking  at  the  bed-clothes,  are  common  symptoms 
of  grave  import.  Obstinate  hiccough  is  often  present,  and  is 
a  sign  of  great  gravity.  Involuntary  evacuations  of  both 
bladder  and  bowel  are  common,  the  pulse  is  rapid,  very  small 
and  easily  compressible,  while  the  respirations  are  shallow, 
rapid,  and  at  the  same  time  noisy.  It  is  just  before  this  phase 
of  the  disease  develops  that  the  eruption  tends  to  become 
''fixed,"  and  definite  petechias  appear. 

In  favourable  cases  crisis  occurs  about  the  fourteenth 
day,  and  there  is  a  more  or  less  sudden  improvement  in  the 
condition  of  the  patient.  The  temperature  falls,  the  wakeful 
delirium  passes  away,  the  skin,  M-hich  has  been  harsh  and  dry 
all  through  the  attack,  grows  moist,  and  the  patient  A^ery 
often  falls  into  a  natural  sleep,  which  may  last  for  many 
hours,  and  fi-om  which  he  awakes,  weak  and  prostrated  but 
conscious  of  his  surroundings.     The  tongue  grows  moist,  loses 


1'yi)hus.  325 

its  shrivelled  appearance,  and  beg-ius  i-o  clojin  at  tlie  edgtw  and 
tip.  The  mouth  becomes  clean,  sordes  can  be  successfully 
removed,  and  do  not  tend  to  collect  again,  the  breath  loses 
its  offensive  smell,  the  eyes  become  clear,  and  the  pulse  grows 
fuller  and  less  rapid.  As  in  pneumonia,  "  critical  discharges  " 
are  quite  common,  profuse  drenching  sweats  may  occur,  the 
bowels  may  suddenly  show  a  tendency  to  looseness,  and  the 
urine,  which  during  the  whole  of  the  attack  has  probably  been 
scanty  and  highly  coloured,  although  fairly  clear,  is  passed  in 
greater  quantity,  and  may  be  loaded  with  urates  and  uric  acid. 

After  the  occurrence  of  the  crisis  the  patient  enters 
rapidly  upon  the  stage  of  convalescence.  The  tongue  cleans, 
muscular  strength  returns,  and  appetite  grows  with  extra- 
ordinary rapidity.  In  many  cases  the  appetite  of  the  patient 
convalescent  from  typhus  fever  is  excessive,  and  he  can 
scarcely  be  satisfied  with  food.  In  the  majority  of  uncom- 
plicated cases  the  patient  regains  health  and  vigour  very 
rapidly,  so  that  in  three  or  four  weeks  convalescence  may  be 
complete. 

The  temperature  in  typhus  fever  follows,  in  classical 
cases,  a  very  definite  and  regular  course.  It  rises  somewhat 
rapidly  during  the  period  of  invasion,  reaching  a  height  of 
103°  or  104°  F.  by  the  fourth  day.  This  ascent  is  commonly 
by  "steps  and  stairs."  While  the  temperature  on  the  second 
day  of  the  disease  is  usually  definitely  febrile,  in  some  cases 
the  onset  of  the  pyrexia  is  very  gradual,  so  that  even  at  the 
end  of  the  second  day  it  maj  be  only  raised  to  about  100°  F. 
By  the  fourth  day,  however,  it  is  always  high,  and  may  reach 
104°  F.  or  even  higher.  Hereafter  the  fever  is  a  ''continued" 
type  until  early  in  the  second  week  of  illness,  usually  between 
the  seventh  and  tenth  days,  when  there  is  frequently  a  well- 
marked  remission,  or  ''pseudo-crisis."  In  most  cases  this 
pseudo-crisis  is  followed  by  a  second  rise  in  temperature  about 
the  eleventh  day,  and  the  fever  again  assumes  a  "  continued  " 
type  until  the  final  stage  of  defervescence  begins.  In  favour- 
able cases  the  second  rise  in  temperature  does  not  reach  the 
same  height  as  during  the  first  period  of  continued  fever.  In 
some  instances  the  pseudo-crisis  is  followed  by  a  gradual  lysis 
^mtil  the  normal  is  reached  on  or  about  the  fourteenth  day. 


326  Chapter  XX. 

The  most  u.sual  terniiiKitioii  of  the  fever  is,  liowever,  b}^  a 
distinct  crisis,  which  follows  on  the  second  period  of  coutiuued 
fever,  and  which  begins  somewhere  between  tlie  thirteenth  and 
fourteenth  day,  and  finishes  between  the  fourteenth  and 
fifteenth.  In  some  cases  the  crisis  is  extraordinaril}^  rapid, 
and  the  temperature  maj-  fall  in  a  few  hours,  certainly  within 
twenty-four,  from  a  highly  febrile  register  to  normal  or  sub- 
normal. 

In  certain  very  mild  cases  of  typhus  the  fall  in  temjDera- 
ture  which  occurs  early  in  the  second  week  of  the  disease  may 
be  complete  and  final,  and  a  true  crisis  may  terminate  the 
attack  at  this  period.  On  the  other  hand,  in  certain  severe 
cases  there  may  be  no  such  remission  of  temperature  between 
the  seventh  and  the  tenth  days,  and  the  pyrexia  at  this  time 
may  steadily  increase,  and  death  may  occur  before  the  four- 
teenth day,  with  very  pronounced  hyperpyrexia. 

The  pulse  all  through  the  attack  A^aries  more  or  less  cor- 
rectly in  the  majority  of  cases  with  the  degree  of  fever. 

One  feature  of  typhus  fever  which  is  not  common  to  all 
the  infectious  fevers  is  that  in  this  disease  the  odour  of  the 
patient  is  in  many  cases  characteristic.  The  odour  has  been 
described  as  ''mousy,"  or  like  the  smell  of  rotten  straw,  and, 
to  those  who  are  familiar  with  typhus,  it  is  strikingly  charac- 
teristic. I  have  heard  the  late  Dr.  J.  B.  Hussell,  formerly 
Medical  Ofl&cer  of  Health  for  Glasgow,  say  that  in  the  old 
days,  when  typhus  was  rife  in  that  city,  he  was  able,  more 
often  than  not,  to  know  that  a  typhus  patient  w^as  in  a  room 
simply  by  the  smell.  This  odour  appears  to  be  given  off  from 
the  skin,  and  is  probably  present  at  one  time  or  another  during 
the  course  of  the  disease  in  all  cases  of  typhus,  except  those 
of  a  very  mild  type.  It  uaay  even  persist  during  the  period 
of  convalescence. 

While  the  odour  is  in  my  opinion  only  slightly  reminis- 
cent of  the  smell  of  mice,  a  note  made  by  Brownlee  of  Glasgow 
in  a  recent  report  would  seem  to  show  that  there  is  consider- 
able reason  for  this  description  of  it.  A  large  cupboard  in 
the  administrative  office  was  occupied  by  old  bed  cards  from 
all  the  wards  in  Belvidere  Fever  Hospital.  The  place  was 
infested  with  mice,  and  it  is  interesting  to  note  that,  although 


7' y '/ill  us.  '>2T 

the  bed  cards  wore  collected  from  all  tlie  wards  of  tlie  iiospita], 
and  represented  patients  suffering  from  all  the  inf(!ctious 
fevers,  it  was  only  those  cards  wiii(;li  Imd  conu;  froin  the  typhus 
wards  which,  were  nibbled  by  tJie  niice;  llie  oilicrs  Jiad  l>een  left 
severely  alone. 

The  clinical  description  of  typhus  fever  j^nven  above  is 
that  of  the  ordinary  classical  type  of  the  disease,  1)ut  the 
disease  may  present  features  of  greater  or  lesser  severity  than 
have  been  included  in  that  description. 

A  fuhninant  type  is  soimetimes  met  with,  in  which  tiie 
patient  is  struck  down  with  extraordinary  rapidity,  and  may 
become  comatose  in  a  few  days,  dying,  as  a  rule  Avith  high 
fever  and  a  rapidly  failing  pulse,  just  about  the  time  the 
eruption  should  appear,  or  only  a  day  or  so  afterwards.  This 
type  of  the  disease  is  with  difficulty  recognisable  unless  the 
case  arises  in  conjunction  with  other  definite  cases  of  typhus. 

A  severe  type  of  the  disease  is  that  in  which  signs  of 
nervous  excitement  with  restlessness  and  delirium  set  in  earlier 
than  usual,  and  in  these  cases  death  may  occur  on  or  about 
the  twelfth  day  of  illness.  For  some  time  before  death  the 
patient  sinks  into  a  condition  of  coma,  lying  with 
open  eyes,  which  have  a  vacant  look,  with  widely  dilated 
j)upils.  The  mouth  is  open,  the  face  pale  and  livid;  the  pulse 
is  very  rapid  and  weak,  and  may  be  imperceptible  at  the 
wrist ;  the  breathing  is  very  shallow ;  the  surface  of  the  body 
generally  is  cold  and  clammy,  and  sometimes  bathed  in  sweat. 
Death  always  occurs  when  this  stage  of  wakeful  coma  is 
reached.  In  other  cases  which  begin  similarly  there  is  no 
such  wakeful  coma,  but  the  patient  dies  after  sudden  and 
extensive  congestion  of  the  lungs.  In  other  cases,  again,  the 
heart  may  fail  suddenly;  the  surface  of  the  body  becomes  cold 
and  livid,  and  the  patient  may  suffer  from  profuse  sweating. 

In  many  of  these  severe  cases  the  temperature  may  be 
quite  moderate,  perhaps  not  exceeding  101°  or  102°  F.  It  is 
sometimes  irregular  in  character,  with  considerable  dailv 
variation,  while  in  other  cases  the  fever  may  be  ''  continued  " 
with  practically  no  morning  remissions.  In  those  cases  where 
cardiac  failure  is  marked,  the  range  of  temperature  often  tends 
to  become  lower,  while  at  the  same  time  the  pulse  rate  rises. 


Z    L» 


328  Cliaiiter  XX. 

In  certain  severe  cases,  on  tLe  other  liand,  llie  temperature 
may  run  more  or  less  the  usual  highly  febrile  course,  until 
between  the  twelfth  and  fourteenth  day  it  begins  to  fall  by 
a  rapid  lysis,  with,  however,  no  amelioration  of  the  patient's 
symptoms,  death  occurring  with  gradually  increasing  coma 
and  a  rapidly  rising  pulse  rate. 

In  great  contrast  to  those  severer  forms  of  the  disease  are 
the  mild  forms  Avhich  are  very  often  seen  in  children,  and  not 
infrequently  nowadays  in  adults.  In  such  cases  the  course  of 
the  disease  is  usually  distinctly  shorter  than  in  the  classical 
type.  The  temperature  falls  to  normal  as  a  rule  between  the 
seventh  and  twelfth  days,  either  by  crisis  or  by  a  rapid  lysis. 
Termination  by  lysis  is  very  common  in  children.  In  those  mild 
cases  the  rash  is  usually  scanty,  and  may  consist  only  of  sub- 
cuticular mottling,  followed  in  due  course  by  the  appearance 
of  a  few-  petechise.  The  patient  may  not  lose  consciousness 
during  the  whole  course  of  the  fever,  although  there  may  be 
considerable  pyrexia  from  the  fourth  or  fifth  day  until  the 
termination  of  the  attack.  There  may  be  no  signs  of  nervous 
excitement,  and  no  indication  of  cardiac  weakness. 

During  the  course  of  an  epidemic  of  tj^phus  cases  may  be 
met  with  which  present  no  definite  signs  of  disease  beyond 
headache,  nausea,  and  general  malaise,  with  some  rise  of  tem- 
perature. In  these  cases  the  attack  may  last  only  for  about  a 
week,  and  the  type  of  the  disease  is  perhaps  best  described  as 
typhus  febricula. 

There  are  certain  unfavourable  signs  in  the  course  of  a 
case  of  typhus  which  may  be  mentioned  with  a  view  to  prog- 
nosis. 

A  history  of  alcoholism  always  makes  the  prognosis  grave, 
and  an}"  pre-existing  cardiac  lesion  is  a  heavy  weight  for  the 
typhus  patient  to  carry.  There  is  no  doubt,  too,  that  a  large 
and  heavy  person,  whether  muscular  or  merely  fat,  has  a 
worse  chance  of  weathering  an  attack  of  typhus  than  a  person 
who  is  spare  and  of  slight  build.  Indeed,  one  has  often  seen 
a  spare,  wizened  alcoholic  recover  from  an  attack  of  typhus, 
while  a  heavy,  bulky  man  of  strictly  temperate  habits  has 
succumbed. 


T,//>ln/.s.  '.V>\) 

Severe  'nervovs  syvi/ptoms,  especially  wild  delirium  and 
coma,  point  to  a  fatal  termination,  and  .suhsulfus  tendinwm, 
carpJiology,  and  iironounced  muscular  txoitcliin(j  are  also  of 
bad  omen. 

A  pulse-rate  over  120  is  an  unfavourable  sign,  as  is  also 
a  respiration  rate  which  approaches  or  exceeds  40  in  the 
minute. 

A  patient  who  sleeps  badly  has  much  less  chance  of 
recovery  than  a  patient  who  gets  a  fair  amount  of  sleep. 

Pinhole  'pvpils  are  also  an  unfavourable  indication. 

A  profuse  eruption  with  many  petechia?  suggests  a  severe 
infection,  and  hypostatic  staining  of  the  hack  denotes  a  degree 
of  circulatory  stasis  which  is  an  immediate  precursor  of  death. 

A  temperature  which  shows  very  little  morning  remission 
usually  indicates  a  case  of  greater  gravity  than  when  the 
morning  remissions  are  well  marked,  and  should  the  tempera- 
ture tend  to  rise  rather  than  fall  about  the  time  when  the 
crisis  may  occur,  it  may  be  taken  as  a  very  unfavourable 
indication. 

Profuse  and  continuous  sweating  at  the  time  of  the  crisis 
is  suggestive  of  profound  asthenia,  and  lividity  of  the  skin, 
paralysis  of  the  sphincters  early  in  the  second  week  of  illness, 
and  hiccough  are  all  signs  of  the  gravest  import.  An  absence 
of  the  cardiac  impulse,  with  a  first  sound  that  is  practically 
inaudible  at  the  apex,  indicates  a  degree  of  cardiac  weakness  so 
great  as  to  make  it  extremely  unlikely  that  the  patient  will 
weather  the  attack. 

Complications.  —  The  more  common  complications  of 
typhus  are  in  connection  with  the  respiratory  tract,  the  heart, 
and  the  Iddneys.  Venous  thrombosis  and  lymphangitis  are 
very  common  in  some  epidemics,  and  parotitis  is  also  not 
unusual. 

Of  the  complications  connected  with  the  respiratory  tract, 
bronchitis  is  the  most  frequent.  It  is  widely  diffused,  and 
affects  not  only  the  larger  but  the  finer  bronchi.  This,  com- 
bined with  the  tendency  to  hypostatic  congestion  of  the  lungs 
which  is  such  a  common  feature  of  the  disease,  may  give  rise 
to  a  condition  of  great  gravity.  The  patient  lies  naturally  in 
the  dorsal  decubitus  in  typhus,   and  this  position,   combined 


330  Chapter  XX. 

with  liis  g-veat  iiuiscular  weakness,  makes  it  very  difficult  for 
liiiii  to  clear  tlie  bronclii  of  secretion,  the  more  so  as  secretion 
in  cases  of  typhus  complicnted  hy  broncliitis  is  usually  very 
profuse.  This  complication  may  arise  at  any  time  in  typhus 
after  the  first  few  days,  and  is  a  very  common  cause  of  death. 
The  patient  becomes  cyanosed,  breathing  becomes  increasingly 
difficult,  and  death  occurs  either  just  before  the  crisis  is 
expected,  or  as  it  occurs.  Sometimes  the  bronchitis  is  slight, 
affecting  chiefly  the  larger  bronchi,  and  may  not  influence  the 
course  of  the  disease  unfavourably.  The  occurrence  of  bron- 
chitis, however,  early  in  the  attack,  especially  if  it  be  at  all 
diffuse  and  if  the  finer  bronchi  are  affected,  should  always  lead 
one  to  give  a  grave  prognosis. 

An  ac-ute  imeiimonia  of  the  lobar  type  is  also  sometimas 
seen,  but  is  rare.  When  it  does  occur  it  is  a  sign  of  extreme 
gravity,  and  usually  leads  to  a  fatal  termination. 

Laryngitis  is  another  complication  which  is  not 
common,  but  is  extremely  dangerous,  largely  on  account 
of  the  fact  that  acute  ozdema  of  the  glottis  may 
occur  in  such  cases  with  ra^jid  suft'ocation,  or  necrosis  and 
gangrene  of  the  laryngeal  cartilages  may  result.  Death  very 
frequently  follows  on  the  occurrence  of  these  complications, 
which  are  indicative  of  an  extremely  profound  toxaemia. 

Gangrene  of  the  lung  has  been  known  to  occur,  and 
pleurisy  is  sometimes  met  with,  usually  accompanied  by  an 
effusion  which  rapidly  becomes  purulent. 

A  rare  and  interesting  complication  is  licBinoptysis,  which 
is  usually  seen  in  cases  which  present  otherw^ise  a  hsemorrhagic 
tj^pe  of  the  disease,  and  is  due  probably  to  alteration  in  the 
condition  of  the  blood  and  weakening  of  the  vessel  walls  from 
the  action  of  the  typhus  poison. 

While  endocarditis  and  pericarditis  are  rarely  met  with 
in  the  course  of  typhus,  cardiac  distress  is  very  common,  and 
is  due  to  the  effect  on  the  cardiac  muscle  of  the  typhus  toxins. 
This  may  be  so  severe  as  to  cause  an  acute  granular  disintegra- 
tion of  the  Tnuscular  fibres,  with  rapid  and  complete  heart 
failure.  From  the  date  of  the  appearance  of  the  rash,  even  in 
favourable  cases,  the  heart  is  weak  in  action  for  about  a  week. 
In  favourable  cases,  however,  there  is  some  recovery  of  cardiac 


Typhus.  'VM 

strength  before  the  crisis  occurs,  uud  with  tlu!  crisis  evidence 
of  cardiac  distress  disappears.  In  unfavoura})le  cases,  how- 
ever, cardiac  weakness  becomes  increasingly  apparent  from  tbo 
time  of  the  appearance  of  the  rash  until  the  fatal  termination 
of  the  attack,  which  may  be  just  before  the  time  at  which  the 
crisis  is  expected,  or  at  the  time  of  its  occurrence,  when  a  fall- 
ing temperature  and  a  rising  pulse  rate  give  indication  of  the 
approaching  end. 

Simple  albuminuria  is  so  common  in  tlie  course  of  the; 
fever  as  not  to  be  reckoned  as  a  complication,  but  in  some  cases 
a  true  nephritis  occurs,  with  hasmaturia,  profuse  albuminuria 
and  tube-casts,  accompanied  by  signs  of  urrrwia.  Death  may 
ensue  in  such  cases  after  the  occurrence  of  convulsions  and 
coma,  which  are  probably  ursemic  in  origin.  Cystitis  is  some- 
times seen,  and  is  secondary,  as  a  rule,  to  great  weakness  of 
the  bladder  wall,  with  resulting  over-distention  and  incom- 
plete emptying  of  the  bladder.  At  times  cystitis  has  been 
known  to  be  associated  with  hce^naturia.  Hmviaturia  may  also 
result  in  a  hsemorrhagic  or  hsemolytic  type  of  the  disease 
from  the  altered  condition  of  the  blood  and  small  vessels. 

Thrombosis  of  one  or  other  of  the  femoral  veins  is  not 
uncommon,  but  it  is  probable  that  most  cases  of  "  white  leg  ' 
which  occur  in  the  course  of  typhus  are  due,  as  in  enteric 
fever,  not  to  venous  thrombosis,  but  to  a  diffuse  lymphangitis. 
In  some  epidemics  "  white  leg  "  is  a  comparatively  common 
occurrence. 

Parotitis  is  another  complication  which  is  not  infrequently 
seen.  It  usually  results  in  suppuration,  with  sloughing  of 
the  surrounding  parts,  and  is  a  sign  of  a  grave  infection, 
although  it  does  not  necessarily  indicate  a  fatal  termination. 
Parotitis  usually  appears  some  days  before  the  crisis  is 
expected,  but  it  may  also  occur  early  in  convalescence. 

Bubonic  sweUings  of  various  groups  of  lymphatic  glands 
sometimes  occur,  and  their  commonest  situations  are  in  the 
cervical  region  and  the  groin.  They  appear,  like  parotitis, 
either  shortly  before  the  crisis  is  expected,  or  very  early  in 
convalescence,  and  they  may  either  suppurate  or  subside  with- 
out suppuration.  When  suppuratioii  occurs,  it  is  frequently 
associated    with     a    considerable     amount   of    sloughing     and 


;«2  Chapter  XX. 

gangrene  of  the  surrounding  parts,  and  a  A'ery  ugly  sore  results 
which  may  take  a  long  time  to  heal. 

Diarrhoea  may  be  sometimes  so  urgent  as  to  "warrant  its 
being  considered  a  complication  of  typhus,  and  is,  in  the 
weakened  state  of  the  patient,  a  grave  danger.  Hcemorrhage 
frovi  the  boirel  and  hccmateviesis  may  occur,  but  are 
uncommon,  and  indicate  a  hsemorrhagic  type  of  the  disease 
rather  than  the  existence  of  any  local  lesion. 

Otitis  media,  small  multi'ple  'pyoRmic  abscesses  and 
troublesome  crops  of  boils  are  also  occasionally  met  with,  either 
towards  the  end  of  the  fever  or  at  the  beginning  of  convales- 
cence. 

Although  nervous  symptoms  are  so  usual  in  the  course  of 
the  disease,  any  gross  lesion  of  the  nervous  system  is  rare. 
Meningitis,  however,  may  occur,  and  hemiplegia  may  result 
from  cerebral  haemorrhage,  embolism,  or  thrombosis. 

Jaundice  is  a  rare  complication  which  invariably  indicates 
a  fatal  termination  for  the  disease. 

Sequelae.  —  Beyond  the  occurrence  of  venous  throTn- 
bosis,  parotitis,  bubonic  swellings  of  lymphatic  glands,  boils, 
and  other  indications  of  pyogenic  infection,  the  sequelae  of 
typhus  fever  are  few,  and  convalescence  is  usually  rapid  and 
complete  after  the  occurrence  of  the  crisis. 

In  some  rare  instances,  however,  various  sequelae  may 
occur  in  connection  with  the  nervous  system.  Peripherdl 
neuritis  is  probably  the  cause  of  the  muscular  pains  which 
sometimes  complicate  and  protract  convalescence.  Paraplegia, 
with  increased  knee  reflexes,  has  also  been  noted  occasionally 
in  patients  convalescent  from  typhus.  Some  degree  of 
mental  weakness,  or  even  more  rarely,  mania,  may  occur  as 
convalescence  is  established.  Fortunately,  all  these  conditions 
are  quite  transient,  and  even  mental  weakness  and  mania  rarely 
persist  longer  than  a  few  months.  In  a  few  instances,  how- 
ever, it  would  seem  as  if  the  mental  attitude  of  the  patient 
had  been  permanently  changed  by  the  attack  of  typhus.  Such 
an  occurrence  is,  fortunately',  of  extreme  rarity. 

Diagnosis. — When  an  epidemic  of  typhus  is  in  progress, 
diagnosis  of  the  disease,  even  at  an  early  stage,  is  not  as  a  rule 
a  very  difficult  matter.     The  heavy  congested  face,   injected 


Typhus.  333 

eyes,  and  confused  mental  state  are  all  very  suggestive,  and  if 
in  addition  the  attack  lias  been  ushered  in  hy  headache,  shiver- 
ing, and  vomiting,  the  presumption  of  its  being  a  case  of 
typhus  is  very  strong. 

In  the  early  eruptive  stage  the  classical  rash  is  very 
characteristic,  but  it  is  to  be  remembered  that  it  may  consist 
only  of  a  subcuticular  mottling,  which  is  difficult  to  recognise, 
except  after  considerable  experience. 

If  the  morbilliform  elements  of  the  rash  are  well  marked 
it  is  possible  that  the  case  may  be  confused  with  measles y 
although  the  early  catarrhal  symptoms  in  measles  and  the 
profuseness  of  the  rash  should  make  such  confusion  difficult. 
Moreover,  measles  is  essentially  a  disease  of  childhood,  and 
the  rash  in  children  is  quite  as  profuse  as  in  adults,  whereas 
in  typhus  fever  the  morbilliform  rash  in  children  is  slight, 
modified  and  sometimes  entirely  absent. 

The  petechial  elements  of  the  rash  resemble  the  fixed 
eruption  met  with  in  hmmorrJiagic  enteric  fever,  true  purpura 
and  the  purpuric  rash  which  appears  in  certain  non-specific 
infections,  which  may  produce  leukaemia  or  other  profound 
blood  changes.  It  also  resembles  ver^^  closely  the  petechial 
marks  left  by  flea  bites,  but  a  careful  examination  of  a  flea 
bite  will  usually  show  a  small  central  point  which  indicates 
the  original  puncture.  Otherwise,  in  size  and  general  appear- 
ance the  petechial  stage  of  a  flea  bite  resembles  very  closely 
the  small  petechia  of  typhus,  but  the  distribution  is  somewhat 
different,  being  more  profuse  as  a  rule  on  the  arms  and  legs- 
than  on  the  trunk,  although  in  many  cases  the  whole  body  may 
be  covered.  It  is  to  be  remembered,  also,  that  among  the 
class  of  patients  who  are  usually  afflicted  nowadays  with 
typhus,  bites  from  vermin  are  the  rule,  and  one  rarely  finds  a 
case  of  typhus  fever  where  the  true  rash  is  not  accompanied 
by  a  profuse  crop  of  flea  bites. 

In  true  purpura  and  in  haemorrhagic  typhoid  the  pete- 
chial eruption  is  composed  as  a  rule  of  larger  elements  than 
are  commonly  found  in  typhus. 

The  two  diseases  with  which  typhus  is  most  commonly 
confused  in  this  country  are  acute  lohar  pneuTnonia  and  enteric- 
fever. 


334  Chapter  XX. 

An  apical  yneumonia  may  present  no  physical  signs  in 
the  early  days  of  illness,  and,  as  cases  of  apical  pneumonia 
are  so  frequently  accompanied  by  early  mental  disturbance  and 
■even  delirium,  it  may  be  very  difficult  to  make  up  one's  mind 
as  to  the  nature  of  the  case.  Pneumonia  is  a  disease 
whose  onset  is  as  rapid  and  severe  as  that  of  typhus,  and  an 
apical  lesion  is  not  likely  to  be  associated  with  early  pain  in 
the  chest  on  account  of  its  central  beginning.  In  pneumonia, 
ioo,  the  face  may  be  congested  and  flushed,  and  although  in 
such  cases  herpes  of  the  lip  is  very  common,  such  an  occur- 
rence is  also  not  unusual  in  typhus.  An  eruption  of  flea  bites 
may  further  confuse  diagnosis.  In  the  course  of  a  day  or  two, 
liowever,  the  lesion  in  the  lung  will  declare  itself,  and  the 
greatly  increased  frequency  of  respiration  in  early  cases  of 
pneumonia,  combined  with  dilatation  of  the  nostrils  during 
inspiration,  will  make  one  suspect  the  presence  of  an  acute 
pulmonar}^  lesion.  On  the  other  hand,  it  is  not  uncommon  to 
find  a  case  of  typhus  sent  to  hospital  as  pneumonia,  the  physi- 
cian having  been  misled  by  the  sudden  onset  and  acuteness 
■of  the  fever,  and  by  the  finding  of  an  area  of  dullness  at  the 
I)ase  of  one  or  other  lung  behind.  Such  areas  of  dullness  are 
very  common  in  typhus,  even  at  an  early  stage,  on  account  of 
i;he  tendency  to  hypostatic  congestion  of  the  lungs,  and  the 
auscultatory  signs  over  such  areas  of  impaired  percussion, 
namely,  diminution  in  volume  of  the  respiratory  murmur  and 
a  little  inspiratory  crepitus,  are  just  such  as  one  might  expect 
in  the  early  stages  of  a  pneumonia.  Early  mental  confusion 
with  delirium  is  common  in  both  diseases,  especially  in  alco- 
Iiolic  subjects. 

The  main  points  which  one  must  consider  in  a  differential 
diagnosis  of  lobar  pneumonia  from  typhus  are  the  rapidity  of 
the  respiration,  which  is  quite  in  Excess  of  what  is  met  with  in 
typhus  fever  except  in  very  severe  cases  where  the  rash  is 
usually  profuse,  and  the  character  and  distribution  of  the  dull- 
ness over  the  lungs.  A  definite  dullness  at  one  apex  would 
be  strongly  in  favour  of  the  case  being  pneumonia.  A  definite 
dullness  limited  to  one  base  or  lateral  region  would  point  in  a 
similar  direction.  In  typhus  any  impairment  of  percussion 
w'hich  exists  over  the  lungs  behind  is  usually  bi-lateral,  seeing 


Typhus.  335 

that  it  is  due  to  a  hypostatic  congestjon,  iiiid  is  most  iriarkod 
at  the  extreme  bases.  Auscultation  does  not  show  any  such 
tubularity  of  tlie  respiratory  murmur  as  one  meets  witli  in 
pneumonia.  In  those  cases  of  typhus  fever  which  are  compli- 
cated by  pneumonia  tlie  signs  of  consolidation  in  tlio  luns^^s  do 
not  as  a  rule  make  their  appearance  until  the  disease  is 
tliorouglily  established,  and  in  such  cases  the  rash  is  usually 
Avell  marked. 

A  severe  case  of  enteric  fever  may  closely  resemble  typhus. 
It  is  true  that  in  the  majority  of  cases  a  patient  suffering  from 
enteric  fever  comes  under  observation  only  after  many  days  of 
rather  indefinite  illness,  and  the  appearance  of  the  face  is  very 
different  from  that  met  with  in  typhus,  the  general  colour  of 
the  skin  being  pallid  and  Avhat  flush  there  is  confined  more  or 
less  accurately  to  the  malar  regions.  The  eyes  are  seldom 
suffused,  and  the  pupils  are  usually  dilated.  The  rash  of 
enteric  fever,  however  profuse  it  may  be,  is  usually  composed 
of  definite  rose-coloured  lenticular  spots,  which  fade  on  pres- 
sure, and  do  not  tend  to  become  '"  fixed  "  as  the  disease  pro- 
gresses. Diarrhoea  in  enteric  fever  is  the  rule,  and  the  right 
iliac  region  is  usually  somewhat  full,  pressure  over  this 
region  educing  a  certain  amount  of  gurgling.  The  onset  of 
enteric  fever,  however,  is  not  always  gradual.  The  patient 
may  be  struck  down  with  as  great  rapidity  as  in  any  case  of 
typhus  or  pneumonia.  The  pupils  may  be  contracted  and  not 
dilated,  the  eyes  may  be  suffused,  and  the  face  exhibit  a 
general  congestion,  having  no  resemblance  to  the  malar  flush 
which  is  usual  in  enteric.  There  may  be  no  tumidity  or  gurg- 
ling in  the  right  iliac  region,  the  rash  may  be  definitely 
"'fixed,"  and  darker  in  colour  than  is  usual.  To  make  the 
confusion  greater,  such  a  case  of  enteric  fever  may  present 
signs  of  great  nervous  excitement  early  in  the  disease,  and. 
splenic  enlargement  and  a  certain  amount  of  congestion  of  the 
base  of  the  lung  being  common  to  both  diseases,  diagnosis  may 
be  a  very  difficult  matter. 

It  is  usual  to  say  that  a  Widal's  reaction  will  clear  up  the 
diagnosis  promptly  and  effectively,  but.  unfortunately,  this  is 
not  the  case.  It  is  quite  common  to  have  the  reaction  delayed 
in  enteric  fever  until  convalescence  is  established,  especially 


336  Chapter  XX. 

if  the  case  be  a  severe  one,  and  a  positive  Widal's  reaction  in 
small  dilutions  is  quite  common  in  typhus  fever.  It  is  true 
that  a  positive  reaction  obtained  with  high  dilutions  is  prob- 
ably quite  diagnostic  of  enteric  fever,  since  a  positive  reaction 
is  obtained  in  typhus  only  in  comparatively  low  dilutions,  but 
a  negative  Widal  obtained  at  such  a  stage  of  the  illness  as 
is  likely  to  be  confused  with  typhus  fever  is  no  evidence,  taken 
by  itself,  in  one  direction  or  the  other.  A  positive  Widal, 
however,  is  an  important  addition  to  evidence  in  conjunction 
with  other  differential  points,  such  as  the  appearance  of  defi- 
nite lenticular  spots,  which  are  not  ''fixed,"  and  evidence  of 
some  local  lesion  in  the  abdomen.  The  fact  that  a  negative 
Widal  is  so  common  in  enteric  fever  just  at  that  stage  of  the 
disease  where  differentiation  is  otherwise  difficult,  has  led  one 
to  rely  much  more  strongly  upon  the  isolation  of  the  bacillus 
typhosus  from  the  blood,  and  where  the  diagnosis  is  doubtful 
such  an  examination  of  the  blood  should  always  be  made. 

The  odour  of  typhus  may  be  a  considerable  aid  to  the 
differential  diagnosis  in  such  cases. 

One  is  very  often  forced  in  cases  of  this  kind  to  rely  upon 
the  history.  Cases  of  enteric  fever  with  sudden  onset  are  very 
uncommon,  and,  as  a  rule,  before  a  case  of  enteric  fever  has 
assumed  the  facies  of  typhus  with  its  congested  face,  suffused 
eyes  and  contracted  pupils,  the  disease  has  lasted  for  nearly  a 
fortnight.  In  cases  where  the  history  is  of  no  help,  one's 
diagnosis  must  rest  on  the  development  of  the  case  and  the 
occurrence  of  a  crisis  about  the  fourteenth  day  of  illness.  Some- 
times only  a  post-mortem  examination  will  clear  up  the  case. 

In  ordinary  purinira,  fever  is  very  uncommon,  the  disease 
is  not  accompanied  by  nervous  symptoms,  and  there  is  a  great 
tendency  to  bleeding  from  the  mucous  surfaces.  The  spots  in 
true  purpura  are,  as  mentioned  before,  very  much  larger  than 
the  petechise  of  typhus.  Occasionally,  however,  one  sees  as  a 
result  of  some  obscure  general  pyogenic  infection,  a  febrile 
illness  associated  with  a  purpuric  eruption  and  enlargement  of 
the  spleen,  which,  although  not  accompanied  by  any  cerebral 
symptoms,  might  to  the  unlearned  suggest  typhus  fever.  In 
such  cases,  however,  the  face  as  a  rule  shows  extreme  pallor, 
and  an  examination  of  the  blood  reveals  either  a  destruction 


Typhus.  337 

of  all  tlie  blood  elements  or  a  definite  leukaemia,  wliicli  places 
the  diagnosis  beyond  question. 

Menhifjit'iH  is  another  disease  which  may  be  confused  with 
typhus,  especially  if  the  meningitis  be  of  the  epidemic  cerebro- 
spinal form.  There  is  often  very  little  or  no  head  retraction 
in  the  early  days  of  a  case  of  cerebro-spinal  meningitis,  and 
petechia3  are  frequently  present  on  the  skin.  In  such  cases 
the  petechias  are  larger  and  less  numerous  and 
the  patient  is  more  irritable  and  hyper-sensitive  than  is  the 
case  in  typhus,  in  which  the  sufferer  is  usually  dull  and 
apathetic.  The  meningeal  cry,  also,  is  not  met  with  in  typhus, 
and  squint,  ptosis,  and  inequality  of  the  pupils,  which  are 
very  characteristic  of  meningitis,  are  signs  of  extreme  rarity 
in  typhus.  Where  real  doubt  exists  as  to  a  case  being  one 
of  cerebro-spinal  meningitis  or  typhus,  a  lumbar  puncture 
should  be  performed,  and  the  characters  of  the  cells  and  the 
presence  or  absence  of  the  diplococcus  intra- cellularis  will  clear 
up  the  diagnosis. 

The  uroemic  state  may  resemble  typhus,  in  spite  of  no 
rash  being  present,  but  in  such  cases  the  fact  that  the 
temperature  is  norm.al  or  sub-normal  should  readily  establish 
a  differentiation. 

Treatment. — In  the  treatment  of  typhus  one  of  the 
great  essentials  is  that  the  patient  shall  be  nursed  in  an  apart- 
ment that  is  large,  clean,  and  particularly  well  ventilated.  It 
is  wise  to  allow  in  hospital  3,000  cubic  feet  of  air  space  for 
each  typhus  patient.  The  ward  should  be  kept  at  a  low  tem- 
perature, and  the  patient's  bed-clothes  should  be  few  and  light. 
The  ventilation  must  be  by  open  windows,  so  that  a 
free  current  of  fresh  air  is  always  in  circulation  in  the  ward. 
In  this  way  risk  of  infection  is  greatly  minimised,  and  a  con- 
stant current  of  cool  air  is  very  grateful  to  the  patients  who 
are  suffering  from  high  fever. 

The  great  muscular  weakness  of  the  patient  and  the  ten- 
dency to  cardiac  failure  to  which  he  is  prone,  make  it  neces- 
sary, almost  more  so  than  in  any  other  acute  fever  except  pneu- 
monia, to  avoid  any  attempt  to  reduce  the  temperature  bv 
means  of  anti-pyretic  drugs. 


338  Chapter  XX. 

Sponging  of  the  surface  of  the  body  with  tepid  water  is 
advisable  for  patients  who  are  showing  a  high  temperature, 
say,  over  104°  F.,  especially  as  this  treatment  not  only  tends  to 
lower  the  temperature  for  a  time,  but  is  very  comforting  to  the 
patient.  Any  attempt  to  reduce  the  fever  by  the  use  of  cold 
baths  is  not  to  be  encouraged,  as  the  extreme  prostration  of 
the  patient  is  a  distinct  contra-indication  to  any  movement 
beyond  turning  in  bed.  It  is  wise  to  sponge  the  back,  sacral 
region  and  hips  wdth  spirit,  as  this  process  tends  to  harden 
the  skin,  and  prevent  the  occurrence  of  pressure  sores,  which 
are,  however,  much  less  common  in  tj'phus  than  in  enteric 
fever. 

On  the  occurrence  of  the  crisis  the  patient's  bedclothes 
should  be  increased  to  avoid  any  chance  of  his  being  chilled. 
Shortly  after  the  crisis  is  complete  and  the  temperature  has 
finally  settled,  the  patient  should  be  removed  to  a  convalescent 
ward,  which  ought  to  be  kept  at  a  higher  temperature  than  the 
acute  ward,  and  the  bed-clothes  may  be  increased  according  to 
the  patient's  feelings. 

The  patient's  mouth  must  be  carefully  cleansed  several 
times  a  day,  the  lips  and  teeth  freed  from  sordes,  and  the 
tongue  cleansed  and  rubbed  with  some  antiseptic  preparation,, 
such  as  a  solution  of  boro-glyceride. 

The  greatest  care  must  be  taken  to  see  that  the  patient's 
bladder  is  emptied  frequently  in  the  day,  say  every  four  hours. 
This  is  particularly  necessary  in  typhus  on  account  of  the 
delirium  of  the  patient  and  the  tendency  to  OA^er-distention 
of  the  bladder,  which  follows  on  the  great  weakness  of  its 
walls. 

Sleeplessness  must  be  dealt  with  by  suitable  hypnotics, 
and  opium  is  not  so  useful  a  drug  in  typhus  as  in  most  of  the 
other  acute  fevers,  seeing  that  engorgement  of  the  lungs  and 
persistent  contraction  of  the  pupils  are  always  a  contra-indica- 
tion to  the  use  of  opium,  and  these  two  conditions  are  very 
frequent  in  typhus.  Sulphonal,  in  doses  of  25  to  30  grs.,  com- 
bined with  a  small  quantity  of  alcohol,  is  often  found  to  be  of 
great  service,  and  if  there  is  much  tendency  to  cardiac  failure 
paraldehyde  is  useful  for  quieting  the  patient,  and  producing 
sleep.  A  dose  of  90  minims  is  usually  required  to  have  any 
effect. 


Ty/j/iu.s.  33i) 

It  ia  very  ueccssiiry  in  typhus  that  tlie  patient  .sh(juld  be 
made  to  sleep,  as  if  sleep  is  not  obtained  wild  delirium  is  apt 
to  ensue.  No  patient  should  be  allowed,  if  at  all  jjossible,  to 
pass  more  than  one  sleepless  night,  and  even  when  first  seen 
a  considerable  degree  of  excitement  on  the  part  of  Ihe  patient, 
necessitates  the  giving  of  some  hypnotic,  without  waiting  t<> 
see  if  natural  sleep  will  come  during  the  night  or  not.  In 
typhus  one  can  afford  to  take  no  risks.  When  sulphonal  or 
paraldehyde  are  used  as  hypnotics  they  should  be  repeated  at 
frequent  intervals  until  sleep  is  produced,  or  until  the  amount 
of  the  drug  given  is  so  large  as  to  warrant  the  physician  staying 
his  hand.  The  drugs  may  be  alternated  with  advantage.  In 
some  cases  all  hypnotics  will  fail,  and  despite  the  efforts  of  the 
physician  the  patient  will  remain  sleepless,  restless  and  more 
or  less  violently  delirious,  until  death  occurs. 

The  use  of  alcohol  in  typhus  fever  is  in  most  cases  very 
necessary,  but  care  must  be  taken  that  the  drug  is  given  in 
reasonable  quantities,  and  not  in  the  extravagant  doses  which 
obtained  during  the  last  generation.  It  is  probable  that  most 
young  patients,  say,  under  the  age  of  twenty,  do  better  without 
any  alcohol,  but  it  is  equally  true  that  the  vast  majority  of 
patients  over  thirty  require  some  alcohol  during  the  course  of 
the  attack.  It  is  not  usually  necessary  to  give  it  during  the 
first  week  of  the  fever,  except  in  small  quantities  in  combina- 
tion with  sulphonal  to  procure  sleep.  As  the  patient  enters, 
however,  on  the  second  week  of  illness,  alcohol  may  be  given 

fairly   freely   in   doses,    say,  of  3ii 3^"^-  every   two    hours. 

If,  after  the  administration  of  alcohol,  the  action  of  the  heart 
is  found  to  be  stronger  and  not  so  rapid,  and  the  pulse  becomes 
fuller,  stronger,  and  more  regular,  while  the  dry,  shrivelled 
tongue  grows  moister,  and  delirium  becomes  less  urgent,  the 
drug  is  doing  good  and  should  be  continued.  If,  on  the  other 
hand,  the  pulse  continues  to  be  weak,  rapid  and  irregular,  no 
alteraljion  takes  place  in  the  condition  of  the  tongue,  and 
there  is  no  lessening  of  the  delirium,  alcohol  is  doing  no  good 
and  should  be  discontinued.  In  most  cases  whisky  is  the  best 
form  of  alcohol  to  give,  except  when  there  is  much  diarrhoea, 
in  which  case  brandy  will  be  found  to  answer  better.  A  little 
champagne  will  sometimes  check  a  tendency  to  hiccough, 
especially  if  given  with  ice. 


340  Chapter  XX. 

While  it  is  common  to  delay  the  use  of  alcohol  until  the 
occurrence  of  definite  indications  for  its  administration,  it 
is  well,  should  a  majority  of  cases  in  an  epidemic  show  a  ten- 
dency to  violent  delirium  and  cardiac  failure  early  in  the 
second  week  of  the  disease,  to  give  alcohol  early  in  the  fever 
to  anticipate  the  occurrence  of  such  symptoms  rather  than 
to  wait  for  their  appearance  before  dealing  with  them.  It 
will  be  found  where  alcohol  is  given  early  in  the  fever  that  a 
small  dose,  say  of  3ii-  every  four  hours,  may  make  all 
the  difference  to  the  patient's  comfort,  and  may  greatly  lessen 
the  tendency  to  delirium  and  cardiac  failure.  Even  when  its 
administration  is  begun  early  in  the  fever,  it  will  be  found 
necessary  to  increase  the  dose  as  the  second  week  of  the  disease 
advances. 

It  would  seem  likely  that  certain  cases  are  saved  at  the 
time  of  the  crisis  by  the  use  of  large  quantities  of  alcohol,  and 
no  patient  should  be  allowed  to  die  with  a  falling  temperature 
and  a  rising  pulse  rate  without  alcohol  being  pushed  perhaps 
to  the  extent  of  §i,  or  §ii.  in  the  hour.  The  time  dur- 
ing which  such  excessive  dosage  may  be  necessary  is  very  short, 
and  it  is  not  likely  that  the  physician  will  run  any  risk  of 
poisoning  his  patient  when  the  drug  is  used  in  large  quantities 
solely  in  such  an  emergency.  Those  who  rabidly  oppose  the 
use  of  alcohol  cannot  argue  with  any  truth  that  the  adminis- 
tration of  this  drug  to  a  patient  who  is  unconscious  and 
delirious,  and  suffering  from  an  acute  fever,  can  possibly 
induce  an  alcoholic  habit  when  he  recovers  consciousness.  It 
is  quite  another  thing  when  alcohol  is  used  during  the  convales- 
cence of  a  disease  like  typhus,  when  it  is  quite  unnecessary, 
and  may  well  lead  to  the  formation  of  an  alcoholic  habit  in 
those  who  are  not  very  strong-minded,  and  who  appreciate  the 
slight  exhilaration  and  increased  feeling  of  well-being  which 
follows  on  its  use. 

Where  alcohol  is  apparently  doing  no  good  other  stimu- 
lants may  be  employed.  Ammonium  carhonate,  combined 
with  the  spirit  of  chloroform,  is  often  of  service.  Camphor 
is  a  powerful  diffusible  stimulant,  which  is  often  of  great 
benefit.  A  very  convenient  way  of  administering  camphor  is 
by  making  a  10  per  cent,  solution  of  the  drug  in  almond  oil, 


Typhus.  341 

and  using-  this  solution  as  a  hypodermic  injection.  Musk  is 
another  stimulant  which  lias  had  a  ^-reat  vo^ue  in  the  treat- 
ment of  those  cases  of  typLus  which  show  a  tendency  to  great 
prostration  and  low  muttering  delirium.  It  should  be  given 
in  5  gr.  doses,  repeated  as  required.  One  great  drawback  to 
the  administration  of  musk  is  the  cost  of  tlie  drug,  wln'cli  is  so 
considerable  as  to  make  its  use  almost  impossible  in  hospital 
practice,  but  there  is  no  doubt  tliat  in  many  cases  it  is  an 
admirable  stimulant. 

Certain  of  the  complications  of  typhus  require  special 
treatment.  Bronchitis  and  pulmonary  congestion  may  be 
treated  by  poulticing,  dry  cupping  and  the  use  of  stiniulatiiig 
liniments  externally,  and  ammonium  carbonate  in  small  doses 
of  2  or  3  grs.  internally.  Quinine  in  doses  of  3  to  5  grs.  every 
four  hours  is  often  of  great  service,  and  digitalis  may  be  used 
in  combination  either  with  quinine  or  ammonia.  Strychnine 
is  an  unsatisfactory  drug  in  typhus,  as  it  frequently  tends  to 
increase  the  restlessness  of  the  patient. 

If  constipation  is  present,  enemata  or  small  doses  of  castor 
oil  may  be  given,  but  powerful  purgation  should  be  carefully 
avoided.  If  there  is  much  diarrhoea  it  may  be  treated  by  the 
restriction  of  the  diet  to  boiled  milk  and  lime  water,  and  the 
lower  bowel  should  be  washed  out  by  a  long-tube  enema  of 
sterilised  water  once  a  day.  An  astringent  mixture  is  some- 
times of  service. 

Headache  may  be  relieved  by  5  gr.  doses  of  citrate  of 
caffeine.  Phenacetin,  and  similar  drugs,  should  be  avoided, 
on  account  of  their  tendency  to  depress  the  heart.  Frequently 
changed  cold  application  to  the  head  or  Leiter's  coils  are  often 
of  great  service  in  relieving  headache  and  lessening  delirium. 

If  delirium  is  wild  the  patient  must  be  controlled  by 
wristlets  and  anklets.  Hyoscin  has  been  used  hypodermically 
in  these  cases,  but  the  results  following  its  use  are  not  par- 
ticularly encouraging.  Chloral  is  also  recommended,  but  in  a 
disease  with  such  a  grave  tendency  to  cardiac  failure  as  typhus 
it  is  not  a  very  safe  drug.  It  does,  however,  appear  to  lessen 
the  muscular  twitching,  tremor  and  almost  convulsive 
movements  which  are  present  in  many  severe  cases. 


342  Cha'pter  XX. 

If  there  is  any  indication  of  the  occurrence  of  convulsions 
the  patient  should  be  freely  purged  with  calomel  and  salts,  dry 
cups  and  poultices  should  be  applied  to  the  loins,  and  wet  cup- 
ping is  often  of  service. 

Abscesses  and  boils  must  be  treated  b}-  ordinary  antiseptic 
methods,  and  where  "  white  ley,"  or  thrombosis  of  the  femoral 
veins  occurs,  the  limb  should  be  elevated  and  enveloped  in 
cotton  wool,  and  glycerine  of  belladonna  may  be  applied  on 
strips  of  lint  covered  with  protective  tissue  to  relieve  the  pain. 

If,  during  convalescence,  any  paresis  of  muscles  occurs 
the  condition  will  be  found  to  yield  readily  to  a  generous  diet, 
massage,  and  galvanism. 

Parotitis  and  bubonic  swellings  of  the  lymphatic  glands 
must  be  treated  by  ordinary  antiseptic  methods. 

During  the  first  few  days  of  convalescence  the  patient 
should  be  prevented  from  assuming  the  upright  position,  and 
should  be  carefully  guarded  against  chill. 

Diet. — During  the  acute  stage  of  the  fever,  the  patient's 
diet  should  be  limited  to  a  pint  or  a  pint  and  a  half  of  milk, 
a  pint  of  chicken  broth,  and  a  pint  of  barley  water,  while  at 
the  same  time  he  should  be  encouraged,  or  indeed  forced,  to 
drink  large  quantities  of  water.  There  is  no  doubt  that  the 
drinking  of  large  quantities  of  water  has  an  excellent  effect 
upon  the  condition  of  the  patient,  particularly  as  regards  the 
tongue,  insomnia  and  delirium.  It  is  probable  that  the 
drinking  of  large  quantities  of  water  assists  in  the  elimination 
of  toxins  by  increasing  diuresis. 

About  the  time  of  the  crisis  egg-flip,  sweetened  with 
sugar,  with  a  little  brandy  added  to  it,  is  a  useful  addition 
to  the  fluid  dietary. 

After  the  crisis  is  complete  it  is  not  well  to  satisfy  the 
patient's  appetite  for  the  first  two  or  three  days.  Some  light 
farinaceous  food  may  be  introduced,  with  perhaps  an  occa- 
sional egg,  but  it  is  well  to  wait  until  the  tongue  is  clean  and 
the  pulse  is  settled  before  giving  fish,  fowl  or  mutton.  As  a 
rule,  some  three  or  four  days  after  the  occurrence  of  the  crisis 
the  patient's  diet  may  be  rapidly  increased  until  within  a 
week  a  full  diet  is  taken,  regulated  largely  by  the  patient's 
appetite  and  powers  of  digestion. 


Typhus.  34'j 

Epidemiology. — Of  lai©  years  typhus  has  been  practically 
unknown  in  I^Jugland,  and  is  seen  but  rarely  in  Scotland.  Ire- 
land still  shows  a  tendency  in  its  poorer  districts  to  epidemics 
of  typhus,  but  even  tliere  the  frequency  of  the  disease  is 
gradually  lessening.  "Whereas  in  Glasgow,  forty  years  ago, 
typhus  was  a  scourge  which  took  as  its  toll  an  appreciable 
percentage  of  all  medical  practitioners,  it  is  now  quite  uncom- 
mon to  meet  with  any  regularly  occurring  epidemic  of  the 
disease,  and  when  an  epidemic  does  occur  it  is  usually  so  small 
as  to  be  quite  negligible.  Typhus  is  still  found  to  some  con- 
siderable extent  in  Russia;  it  is  seldom  seen  in  otlicv 
parts  of  Europe,  and  is  practically  unknown  in  the  United 
States  of  America, 

It  is  a  disease  which  is  definitely  connected  with  dirt  and 
overcrowding,  and  the  improvement  of  sanitary  conditions  in 
our  great  cities,  combined  with  energetic  measures  for  the 
isolation  of  all  those  suffering  from  the  disease  and  also  of  all 
contacts,  have  been  the  means  whereby  the  epidemic  prevalence 
of  typhus  has  been  reduced. 

Epidemics  occur,  perhaps,  with  greater  frequency  in  tlie 
colder  months  of  the  year,  presumably  because  at  this  time 
ventilation  of  the  houses  of  the  poor  is  apt  to  be  more  than 
usually  defective. 

No  micro-organism  has  been  discovered  as  the  causal 
agent  of  typhus,  but  there  is  no  doubt  that  some  such  causal 
agent  does  exist. 

The  striking  distance  of  the  infection  of  typhus  is  very 
short,  so  that  in  a  well-ventilated  ward  there  is  very  little 
risk  of  the  disease  spreading  from  patient  to  patient.  It  has 
been  usually  said  that  the  infection  is  carried  by  the  emana- 
tions from  the  patient,  and  it  is  possible  that  such  may  be  the 
case.  But,  from  a  study  of  other  diseases  whose  causal  agent 
is  known,  it  will  appear  likely  that  the  infection  may  be 
present  in  the  blood  stream  and  in  discharges,  and  quite  prob- 
ably is  conveyed  from  patient  to  patient  by  fomites,  or,  whicli 
is  very  probable,  by  the  agency  of  some  intermediary  parasite, 
for  instance,  the  flea.  The  late  Dr.  J.  B.  Eussell,  of  Glasgow, 
used  to  say  that  an  outbreak  of  typhus  spread  naturally  along 
the  side  of  the  street  in  which  the  first  case  had  arisen,  but 

AA    2 


344  Chapter  XX. 

did  not  tend  to  cross  the  street  unless  some  person  had  visited 
over  the  way,  and  afterwards  contracted  the  disease.  Until, 
however,  the  causal  agent  of  typhus  is  definitely  discovered, 
the  method  of  infection  must  be  a  matter  of  pure  conjecture. 
It  appears  as  if  the  disease  were  occasionally  capable  of  being 
conveyed  by  fomites  for  some  considerable  distance.  I  recol- 
lect one  small  epidemic  of  typhus  in  Glasgow  which  seemed 
to  follow  on  the  arrival  to  a  family  resident  in  the  citj^  of  a 
supply  of  stockings  from  the  Outer  Hebrides,  where  typhus 
is  comparatively  common. 

It  may  be  taken  for  granted  that  a  patient  who  is  com- 
pletel}^  convalescent  from  typhus  has  ceased  to  be  infectious. 

The  death  rate  of  typhus  may  vary  in  different  epidemics 
between  about  6%  and  20%.  10%  is  quite  a  usual  death  rate 
in  an  ordinary  epidemic.  In  the  first  five  years  of  life  the  mor- 
tality seems  to  be  most  commonly  about  5  %  or  6%  ;  in  the 
second  five  years  of  life  about  3%  or  4%;  in  the  third  period 
of  five  years  about  2%.  Thereafter  the  mortality  rate  rises 
steadily  wdth  age,  until  between  the  ages  of  thirty  and  forty 
the  death  rate  is  about  35%;  betv/een  forty  and  fifty  a 
little  over  40%;  between  fifty  and  sixty  about  50%,  rising 
to  something  like  80%  in  people  over  seventy.  The  death  rate 
is  higher  among  men  than  among  women,  and  this  is  doubt- 
less connected  with  the  fact  that  among  women  chronic  alco- 
holism is  much  less  than  among  men.  Pre-existing  disease, 
privation,  dirt,  and  anything  which  lessens  vitality,  are  all 
factors  M^hich  wall  tend  to  raise  the  mortality  rate,  which  is 
also  influenced  to  some  extent  by  season,  rising  to  a  maximum 
in  late  winter  and  spring,  and  falling  to  a  minimum  with  the 
incoming  summer. 

Second  attacks  of  typhus  are  not  very  common,  but  do 
occur.  Murchison  himself  had  the  fever  twice.  The  second 
attack  may  be  as  severe  as  the  first,  or  may  be  distinctly 
milder. 

Home  Prophylaxis. — The  strict  isolation  of  patients 
suft'ering  from  typhus  fever  is  absolutely  essential,  and  it  has 
been  found  by  experience  that  efficient  isolation  is  impossible 
in  a  patient's  house  where  the  disease  arises  in  a  community 
of  anv  size.     In  small  isolated  communities,  with  little  or  no 


7\il/)/ivs.  :',-[') 

hospital  ucconitiiodaiioii  at  their  disposal,  it  may  still  be 
necessary  to  deal  witli  the  patient  at  home.  In  sucli  cases  it 
is  necessary  to  cut  otf  entirely  from  the  community,  not  only 
the  patient,  but  all  the  patient's  household.  Efficient  ven- 
tilation and  cleanliness  must  be  insisted  upon,  and  at  the  ter- 
mination of  the  case  the  whole  house  must  be  disinfected,  and 
all  articles  such  as  bedclothes  and  clothing',  and,  indeed,  all 
textile  fabrics,  should  be  destroyed. 

In  towns,  however,  it  is  never  possible  to  nurse  the  patient 
at  home,  and  the  question  of  home  prophylaxis  comes  A^ery 
little  into  any  scheme  for  dealing  with  this  disease. 

Public  Health  Administration. — It  is  on  the  early  recog- 
nition of  cases,  the  strict  isolation  of  patients  in  hospital,  and 
the  equally  strict  isolation  of  all  contacts  during  the  possible 
incubation  period,  combined  with  the  most  rigorous  methods 
of  disinfection  and  the  enforcement  of  sanitary  cleanliness, 
that  success  in  dealing  with  an  epidemic  of  typhus  depends ; 
and  for  the  efficient  public  health  administration  of  the  disease 
it  is  necessary  to  have  a  staff  at  the  disposal  of  the  local 
authority  which  is  thoroughly  acquainted  with  the  disease, 
and  powers  at  the  command  of  the  administration  to  enforce 
the  isolation  of  patients  and  "  contacts,"  and  to  carry  out  the 
most  stringent  methods  of  disinfection  in.  those  houses  in  which 
the  disease  has  occurred.  On  the  removal  of  a  patient  to 
hospital  all  known  "  contacts  "  should  be  isolated  in  a  recep- 
tion house,  and  observed  carefully,  both  night  and  morning, 
with  regard  to  general  symptoms  and  the  occurrence  of  any 
fever  by  competent  practitioners.  On  the  occurrence  of  sus- 
picious symptonas  in  any  "contact,"  he  should  be  at  once 
removed  to  an  observation  ward,  where  his  health  can  be 
studied  at  frequent  intervals,  and  from  which  he  can  be  sent 
on  to  the  typhus  wards  as  soon  as  it  is  apparent  that  he  has 
fallen  a  victim  to  the  disease. 

The  disinfection  of  the  house  in  which  a  case  has  occurred 
should  be  of  the  most  rigorous  description.  Bedclothes  and 
all  washable  wearing  apparel  should  be  soaked  in  some  power- 
ful disinfectant  and  then  boiled  before  being  washed.  Mat- 
tresses may  be  disinfected  by  steam,  but  it  is  far  better  to 
destroy  them,  as  well  as  any  curtains  and  other  textile  fabrics 


346  Chapter  XX. 

which  are  difficult  of  complete  disinfection.  Books  and  furni- 
ture may  be  disinfected  by  a  formalin  spray,  and  the  whole 
interior  of  the  house  should  be  washed  down  with  a  solution 
of  formalin  or  bi-chloride  of  mercury.  Walls  should  be 
stripped  and  re-papered,  whitewashed  surfaces  should  be 
re-done,  and  all  painted  surfaces  must  be  scraped  and  re- 
painted. 

On  the  occurrence  of  a  case  of  tyj^hus  the  whole  neigh- 
bourhood in  which  the  case  has  occurred  demands  very  careful 
and  scrupulous  attention  on  the  part  of  the  sanitary  authori- 
ties with  regard  to  cleanliness  of  entries,  stairs  and  back- 
courts,  and  the  disinfection  and  removal  of  all  rubbish,  and 
demands  also  a  rigid  investigation  into  the  degree  of  over- 
crowding which  obtains  in  the  district.  It  is  usually  found 
during  the  investigation  of  a  neighbourhood  in  which  typhus 
has  broken  out  that  many  of  the  houses  are  so  old  and  badly 
kept  that  proper  disinfection  of  them  in  their  existing  condi- 
tion is  quite  impossible,  and  in  most  urban  communities  the 
local  authority  has  the  power  to  order  the  closing,  re-building 
or  structural  alteration  of  such  buildings,  so  that  the}^  may 
cease  to  be  a  source  of  danger  to  the  community  in  w^hich  they 
exist.  Considerable  hardship  may  arise  in  arbitraiy  action  of 
tliis  kind,  but  when  it  is  remembered  that  it  is  by  the 
rigid  application  of  the  measures  indicated  above  that  Edin- 
burgh and  Glasgow  have  been  practicalh^  freed  from  the  inci- 
dence of  a  disease  which  used  to  attack  man}^  hundreds  in  each 
year,  and  annually  cost  these  cities  large  sums  of  money,  it 
will  be  readily  seen  that  it  is  better  that  the  interests  of  a  few 
should  suffer  for  the  general  good  of  the  community,  than 
that  such  a  state  of  things  should  become  again  possible  in 
our  dav. 


TYPHUS      CHARTS     N°   1.   2.  &  3. 


Chart  (1)    A  mild  case  with  c 


1  tho  1 1th  day.     Note  the  full  of  tempera- 


ture between  the  7th  and  10th  days,  followed  by  a  pre-critical 


;S.-TTfTCfstft^fHf5KT  Sriifij-sw.  am^^ii-^  s  sit*  i^ 

„.         ^   !   '            'l-ff  ^   ^      :      4 p4^ 

".i  ■   IE-   -^'±L''^       .  ■AL 

v\    1 4             i  '    ■ 

■  ^^L'  -           i:Tt  .    -i    Tl 

.,■  ■     ■                     '         ■     '        1  r      1 

ir ;             -^             ■            ,                              ,     ,  , 

::''---'^i'::.:^--iri^7:=\l-^m^^^^ 

,  ■ 

£ll;'®S!li^®l|fiiffiM6fttliiysill|lSfi^:l^^ 

i 


:*: 


=^1^ 


ttK^ 


mw 


Chart  (2)  Moderately  severe  case.  Temperature  on  a  lower  level  between 
7th  and  lOth  days,  Note  slight  rise  of  temperature  on  10th 
and  11th  days,     Attack  terminates  by  a  verj'  rapid  lysis. 


Chart  (3)     Fatal  c 


<*•"■■   »    •    10    1.    a    1)    1.  IS    It                       1 

J\    - 

!L/    tt 

»r          -          J     ^      ■ 

~r 

esi  — : 

r£iT.mmm^w=^^ 

(S) 


(   347 


Chapter  XXI. 

MUMPS. 

Synonyms. — Specific  parotitis;  epidemic  parotitis. 
German :  Zeigenpeter.  , 

French :  Les  oreillons. 


Definition. — An  acute  infectious  disease  characterised 
by  inflammatory  swelling  of  the  parotid  gland. 

Incubation. — The  incubation  period  of  mumps  is  very 
variable,  and  may  be  as  short  as  twelve  or  as  long  as  twenty- 
six  or  twenty-seven  days.  In  the  majority  of  cases  the  incu- 
bation period  is  from  seventeen  to  twenty-one  days,  but  for 
quarantine  purposes  it  is  well  to  reckon  it  as  four  weeks. 

Rash. — K'o  rash  has  been  observed  which  is  specific  in 
this  disease.  Occasionally  in  children  urticarial  eruptions  are 
observed,  as  is  common  in  all  generalised  infections. 

Symptoms  of  Invasion. — While  enlargement  of  the  parotid 

gland  is  frequently  the  first  sign  of  the  disease  which 
is  manifest,  the  enlargement  is  preceded  in  the  majority  of 
cases  by  two  or  three  days  of  general  malaise,  headache,  and 
possibly  vomiting  with  some  elevation  of  temperature.  These 
prodromal  symptoms,  while  usually  existing  for  two  or  three 
days  before  the  appearance  of  the  parotid  swelling,  may  show 
i:heniselves  only  a  few  hours  before  the  gland  begins  to  enlarge. 
Bleeding  from  the  nose,  "ear-ache,"  and  some  degree  of  sore 
throat  are  also  met  with  among  the  symptoms  of  invasion. 

Clinical  Types. — After  a  variable  period  of  invasion  one 
or  other  parotid  gland  begins  to  enlarge,  and  the  swelling  is 
first  seen  just  below  the  ear.  The  swelling  then  spreads  both 
upwards  and  downwards,  until,  at  the  end  of  a  day  or  two,  it 


;U8  Chapter  XXI. 

invades  the  greater  part  of  the  side  oi  tlie  face  and  neck,  Tlie 
swelling  is  extremely  tender,  there  is  much  aching  in  the  jaw. 
and. any  attempt  to  open  the  mouth  is  attended  by  considerable 
pain.  The  gland  becomes  fully  enlarged  in  about  twenty- 
four  to  thirty-six  hours  after  the  first  appearance  of  the  swell- 
ing below  the  ear.  In  cases  wheie  only  one  gland  is  affected, 
the  swelling  remains  without  change  for  a  day  or  two,  after 
reaching  its  maximum,  and  then  subsides  gradually,  disap- 
pearing completely  about  the  tenth  day  of  illness.  More  often 
than  not,  however,  both  parotid  glands  are  affected,  the  second 
swelling  appearing  as  a  rule  a  few  days  later  than  the  first. 
It  runs  a  similar  course  and  is  gone,  like  the  first,  within  ten 
days  of  its  appearance.  In  such  cases  of  double  parotitis  it 
will  be  seen  that  the  duration  of  llie  illness  will  be  close  on  a 
fortnight. 

In  other  cases,  not  only  is  the  parotid  attacked,  but  the 
sub-maxillary  salivary  gland  is  also  aifected,  and  in  such  cases 
the  swelling  may  be  very  large,  extending  from  the  front  of 
the  ear  almost  down  to  the  clavicle.  Sometimes  both  parotids 
and  both  submaxillary  glands  are  involved.  There  is  usually 
an  interval  of  a  day  or  two  between  the  involvement  of  each  set 
of  glands,  and  thus  the  course  of  the  disease  may  be  prolonged 
for  something  like  three  weeks.  In  some  cases  it  has  been 
noted  that  the  second  parotid  gland  has  become  affected  only 
after  some  weeks  have  elapsed  after  the  involvement  of  the 
first,  as  if  the  patient  had  suffered  from  a  true  relapse. 

Early  in  the  course  of  the  parotid  enlargement  the  opening 
of  Stenson's  duct  becomes  visible  as  a  small  red  projection 
from  the  mucous  membrane  of  the  cheek  on  a  level  with  the 
second  upper  molar,  and  it  remains  visible  until  the  swelling 
has    disappeared. 

The  skin  over  the  affected  parotid  is  usually  somewhat 
reddened,  although  it  may  be  quite  pale,  and  palpation  of  the 
swelling  shows  it  to  be  tense,  somewhat  elastic  and  very  tender. 
Movement  of  the  jaw,  particularly  if  both  parotids  are 
involved,  is  ditficult  and  troublesome  on  account  of  the  pain 
it  produces,  and  it  may  be  no  easy  matter  to  persuade  children 
to  take  food  under  these  circumstances. 


Mumps.  349 

There  is  almost  always  a  certain  degree  of  stomatitip 
present  in  addition  to  the  parotitis,  and  some  swelling  and 
inflammation  of  the  tonsils  is  very  common. 

On  account  of  the  difficulty  of  moving  the  jaw,  saliva  is 
apt  to  collect  in  the  mouth  in  a  troublesome  way,  but  this  is- 
not  caused  by  any  increase  in  the  salivary  flow.  In  the  case  of 
patients  who  are  able  to  bring  themselves  to  move  the  jaws 
during  the  acute  period  of  the  attack,  and  in  most  patients 
as  the  swelling  subsides,  dryness  of  the  mouth  owing  to  a  defec- 
tive salivary  flow  is  a  common  complaint. 

So  long  as  the  parotid  gland  is  enlarged  a  certain  amount 
of  pyrexia  is  usual,  and  in  severe  cases  the  fever  may  rise  very 
high.  In  some  mild  cases,  however,  the  disease  runs  an 
afebrile  course  throughout.  The  fever  declines  with  the  sub- 
sidence of  the  glandular  swelling,  and  is,  of  course,  prolonged 
in  those  cases  where  successive  groups  of  glands  become 
involved. 

The  constitutional  disturbance  in  mumps  varies  verj' 
greatly.  In  the  majority  of  cases  it  lessens  as  the 
period  of  invasion  ends  and  the  local  lesion  develops. 
In  many  cases,  however,  the  patient  suffers  from 
general  discomfort,  with  headache  and  anorexia,  until 
the  swelling  of  the  glands  subsides,  and  perhaps  even  for  some 
days  thereafter. 

In  certain  severe  cases  the  skin  over  the  swelling  is  so 
deeply  congested  as  to  be  almost  black. 

The  parotid  swelling  gives  to  the  affected  side  of  the  face 
a  curious  square  look,  and  there  may  be  some  puffiness  and 
swelling  about  the  eyelids  on  the  same  side  as  the  glandular 
enlargement.  The  parotid  swelling  in  almost  all  cases  sub- 
sides without  suppuration. 

Complications. — While  the  local  lesion  never  gives  rise 
to  any  dangerous  symptoms,  certain  complications  may  arise 
which  are  of  the  nature  of  metastases,  and  are  very  trouble- 
some, often  leading  to  serious  results. 

The  most  common  of  these  are  orchitis  in  the  male  and 
mastitis  and  injiaTnmation  of  the  ovaries  in  the  female.  These 
complications  are  not  common  before  the  age  of  puberty,  but 
are     sometimes     seen     before     that     period.        They     make 


350  Chapter  XXI. 

their  appearacce  about  a  week  after  the  beginning  of 
the  parotid  enlargement,  and  are  usually  ushered  in, 
especially  in  the  case  of  orchitis,  by  a  recrudescence  of  the 
symptoms  of  invasion,  and  by  a  rise  of  temperature  which  may 
be  considerable.  The  constitutional  disturbance  is  in  most 
cases  severe  when  orchitis  occurs,  and  the  patient's  expression 
is  pained  and  anxious;  the  face  is  sometimes  pale,  and  the 
whole  appearance  of  the  patient  suggests  collapse.  The 
amount  of  pain  complained  of  in  the  testicle  is  very  variable. 
The  gland  is  always  swollen  and  tender,  but  some  patients 
complain  of  practically  no  pain,  while  in  other  cases  the  pain 
may  be  excruciating  and  the  tenderness  exquisite.  The 
epididymis  usually  escapes  the  inflammatory  process,  but  a 
slight  urethral  discharge  is  sometimes  present.  It  is  usual 
for  the  orchitis  to  subside  in  the  course  of  three  or  four  days, 
certainly  within  a  week.  In  some  cases  the  second  testicle  is 
attacked  a  few  days  later.  The  serious  aspect  of  the  orchitis 
which  complicates  mumps  is  that  it  is  frequently  followed  by 
atrophy  of  the  testicle,  and  cases  have  been  known  where 
atrophy  of  both  testicles  has  followed  an  attack  of  double 
orchitis,  with  resulting  sterility.  In  certain  rare  instances 
orchitis  has  been  noted  as  the  only  local  manifestation  of  the 
infection  of  mumps. 

Mastitis  is,  in  most  instances,  only  a  trifling  complication, 
associated  with  a  certain  amount  of  pain  and  tenderness  in 
the  breast,  usually  subsiding  in  a  few  days  without  having 
given  much  trouble.  Wliile  mastitis  is  a  complication  that 
is  usually  seen  only  in  the  female,  it  has  been  known  to  occur 
in  men  and  even  in  boys. 

InflamTnation  of  the  ovaries  is  usually  expressed  by  tender- 
ness and  a  little  pain  in  the  ovarian  region,  but  any  enlarge- 
ment of  the  glands  is  rarely  great  enough  to  be  evident  on 
palpation. 

Pancreatitis  is  met  with  occasionally,  and  may  be  rela- 
tively frequent  as  a  complication  in  certain  epidemics.  In 
other  epidemics  it  may  never  be  seen.  When  it  does  occur 
the  parotid  swelling  subsides  rapidly,  vomiting  and  constipa- 
tion are  present,  and  there  is  considerable  pain  and  tenderness 
in  the  epigastrium.     In  some  cases  the  abdominal  symptoms 


Muvij/s.  351 

are  quite  alarming';  vomiting  is  severe,  and  the  vomit  may 
contain  blood;  pain  in  the  epigastrium  is  intense,  and  the 
patient  shows  signs  of  collapse.  In  a  few  cases  a  tender 
transverse  swelling  is  discovered  on  paljiation  of  tlie  lower 
epigastrium. 

A  rare  complication  which.,  Avhen  it  occurs,  usually  follows 
on  the  occurrence  of  orchitis  is  Tneningitis.  It  would  appear 
that  recovery  is  the  rule  in.  sucli  cases,  but  unpleasant  sequela- 
have  been  recorded  in  a  few  instances  which  would  lead  one  to 
believe  that  the  inflammatory  process  was  not  limited  to  the 
meninges,  but  that  a  Trienin go- encephalitis  had  existed.  Such 
sequelse  are  unsteadiness  in  walking,  difficulty  in  articulation, 
local  fKiralysis  of  one  arm,  and  temporary  aphasia  with 
■agrapihia. 

In  a  fcAV  cases  the  parotid  swelling  may  go  on  to  sup- 
puration.  In  such  cases  the  suppuration  is  undoubtedly  due 
to  a  secondary  infection  of  the  affected  gland  by  ordinary 
pyogenic  micro-organisms,  and  not  to  the  specific  poison  of 
mumps. 

Sequelae. — The  nutrition  of  the  patient  is  often 
impaired  for  some  considerable  time  after  the  attack  of  mumps, 
and  complete  restoration  to  health  is  frequently  only  attained 
by  persistence  in  a  generous  diet,  the  use  of  iron  and  malt, 
and  perhaps  a  change  of  air. 

Beyond  this  general  impairment  in  nutrition  an  attack  of 
mumps  is  not  followed  as  a  rule  by  any  definite  sequelae,  but, 
as  rare  sequels  of  the  disease,  deafness,  facial  palsy  and  neph- 
ritis may  occur.  Deafness  is  limited  to  one  ear  and  appears 
shortly  after  the  parotid  swelling  has  subsided.  It  may  be 
due  to  an  inflammation  of  the  eustachian  tube  which  spreads 
to  the  middle  ear.  In  such  cases  hearing  is  usually  restored 
by  suitable  treatment.  Another  form  of  deafness  which 
appears  early  in  the  course  of  the  disease  seems  to  result  from 
an  inflammation  of  the  labyrinth,  and  may  be  accompanied 
by  noises  in  the  head  and  attacks  of  vertigo  and  nausea,  or 
even  vomiting.  In  these  cases  the  deafness  is  practically 
always  permanent. 

Facial  palsy  results  probably  from  a  direct  extension  of 
inflammation  to  the  sheath  of  the  facial  nerve  from  the  affected 


352  Chapter  XXI. 

parotid.  Such  a  palsy  may  occur  in  the  second  or  third  week 
of  the  disease,  and  persists  as  a  rule  for  a  month  or  so. 
Recover^'-  is  practically  invariable,  although  the  condition  is 
sometimes  a  little  obstinate. 

Nephritis,  peripheral  neuritis  and  inflannnation  of  the 
optic  nerve  ivith  subsequent  atrophy,  are  extremely  rare 
seqiieltB,  wliicli,  however,  seem  to  occur  now  and  again. 

Speaking  generally,  complications  and  sequelae  of  any 
importance  occur  only  when  the  original  attack  of  mumps  has 
been  severe. 

Diagnosis.— When  an  epidemic  of  mumps  prevails  in 
any  district  the  diagnosis  of  new  cases  is  not  a  difficult  matter. 
A  parotid  swelling  appearing  suddenlj'  in  a  patient  who  has 
hitherto  been  quite  well,  does  not  occur  in  any  other  disease. 
If,  after  the  occurrence  of  an  inflammation  in  one  parotid,  the 
other  becomes  affected  within  a  few  days,  the  diagnosis  is 
beyond  question. 

The  parotitis  which  is  the  principal  lesion  in  mumps 
differs  from  most  other  inflammations  of  the  parotid  gland  in 
that  a  very  slight  enlargement  of  the  gland  is  associated  with 
a  difficulty  in  opening  the  mouth  and  pain  on  mastication  out 
of  all  proportion  to  the  swelling.  This  does  not  occur  in  any 
other  form  of  parotid  enlargement.  The  early  presence,  too,  of 
an  inflamed  and  visible  orifice  of  Stenson's  duct  is  of  assistance 
in  diagnosis.  It  is  of  importance  to  remember  that  in  the 
early  stages  of  an  attack  of  mumps  the  swelling  of  the  parotid 
may  be  very  slight,  and  confined  entirely  to  that  portion  of  the 
gland  immediately  below  the  ear  and  behind  the  ramus  of  the 
jaw.  In  ]numps,  even  this  slight  amount  of  parotid  inflam- 
mation is  attended  by  pain  on  mastication  and  a  considerable 
degree  of  tenderness  over  the  slight  swelling,  which  is  suffi- 
cient in  itself  to  suggest  a  diagnosis  of  specific  jjarotitis. 

Parotitis  occurs,  of  course,  as  a  complication  and  sequela 
of  other  acute  fevers,  Init  only,  as  a  rule,  in  those  cases 
which  are  more  tlian  usually  severe,  and  there  is  little  likeli- 
hood that  this  type  of  parotitis,  which  may  be  described  as 
symptomatic  and  not  specific,  will  be  confused  with  a  true 
attack  of  mumps. 


Mumps.  3u3 

The  gluiidulur  eiilarg-ement,  however,  which  occurs  below 
the  ear  and  about  the  angle  of  the  jaw  in  diphtheria  may  pro- 
duce a  swelling  which  is  superficially  not  at  all  unlike  the 
deformity  produced  in  certain  cases  of  mumps,  where  the 
enlargement  of  the  parotid  gland  is  almost  entirely  down- 
wards and  not  in  front  of  the  ear.  In  such  cases,  however, 
there  is  very  rarely  any  difficulty  in  opening  the  mouth  or 
any  pain  on  mastication,  and  even  in  mild  cases  of  diphtheria, 
without  much  constitutional  disturbance  in  the  early  days  of 
the  disease,  an  examination  of  the  fauces  will  make  the  true 
nature  of  the  case  at  once  apparent,  since  it  is  only  in  cases  of 
faucial  diphtheria  that  enlargement  of  the  cervical  lymphatic 
glands  is  seen.  Cases  of  diphtheria  of  the  primary  nasal  or 
laryngeal  type  do  not  display  any  enlargement  of  the  cervical 
lymjjhatic  glands. 

Mirchamp  has  described  a  test  upon  which  he  places  some 
reliance  in  the  diagnosis  of  mumps  from  other  parotid  enlarge- 
ments, and  which  he  says  is  successful  in  establishing  a  diag- 
nosis even  before  there  is  any  enlargement  of  the  parotid 
gland.  The  test  consists  in  the  application  of  vinegar  to  the 
tongue,  and  Mirchamp  states  that  in  cases  of  mumps  a  painful 
reflex  secretion  of  saliva  occurs  in  the  gland  which  is  already 
enlarged,  or  which  is  about  to  be  affected.  He  also  states  that 
the  reaction  may  be  present  also  in  those  cases  where  there 
is  no  enlargement  of  the  parotid,  but  where  orchitis  constitutes 
the  only  local  manifestation  of  the  disease.  Unfortunately, 
the  value  of  this  reaction  has  not  been  proved  by  other 
observers.  I  have  never  seen  it  in  my  comparatively  limited 
experience  of  epidemic  parotitis,  and  Claude  B.  Ker, 
of  Edinburgh,  whose  experience  of  this  disease  is  considerable, 
states  that  he  has  always  found  the  reaction  negative. 

Parotitis  may  occur  in  cases  of  iodism  and  of  lead  poison- 
ing, but  is  very  gradual  in  onset,  and  is  not  associated  with 
anything  like  the  same  degree  of  pain  and  discomfort  as  in 
the  specific  form  of  the  inflammation. 

It  is  well,  perhaps,  to  emphasise  the  point  once  more  that 
in  an  epidemic  of  mumps  the  only  local  expression  of  the 
disease  may  be  an  inflammation  of  the  testicle,  and  when 
epidemic  parotitis  is  known  to  be  prevalent  it  is  always  wise 


354  Chapter  XXI. 

to  consider  tlie  possibility  of  a  case  of  orchitis  being  due  to 
this  form  of  infection,  and  to  make  careful  enquiry  as  to 
whether  or  not  the  patient  has  been  in  contact  with  any  definite 
case  of  mumps. 

Treatment. — Although  at  first  mumps  may  appear  to 
consist  only  of  a  mild  local  affection  of  the  parotid  glands,  it 
is  well,  in  view  of  the  possibility  of  disagreeable  complications 
or  metastases,  that  all  patients  sufi'ering  from  mumps  should 
be  kept  strictly  in  bed  for  at  least  ten  days  from  the  first 
appearance  of  any  parotid  swelling.  There  is  no  doubt  that 
the  occurrence,  for  instance,  of  orchitis  is  greatly  favoured  by 
careless  handling  of  the  case  in  the  first  stages  of  illness,  and 
in  view  of  the  grave  results  which  may  follow  on  the  occur- 
rence of  an  orchitis,  the  physician  should  guard  against  such  a 
possibility  by  taking  every  precaution  against  exposure  to  chill 
and  over  fatigue,  even  when  the  early  signs  of  the  disease  may 
appear  to  be  trifling.  Of  course,  orchitis  may  occur  even  in 
those  who  are  kept  strictly  at  rest  at  the  beginning  of  the 
illness,  but  careful  management  in  the  early  days  of  the  attack 
will  go  far  to  prevent  the  occurrence  of  such  a  complication. 

The  bowels  should  be  freely  moved  either  by  small  doses  of 
calomel  or  compound  rhubarb  powder,  the  indications  for  the 
use  of  these  aperients  being  a  furred  tongue  and  a  tendency 
to  constipation  or  oifensive  stools. 

Since  there  is  always  a  certain  amount  of  stomatitis 
present  in  mumps,  the  mouth  should  be  kept  clean  by  swabbing 
or  washing  with  a  solution  of  glycothymoline  of  a  strength 
of  1  to  5.  If  the  toilet  of  the  mouth  is  carefully  done  twice 
a  day  it  goes  far  to  prevent  the  occurrence  of  a  spread  of  the 
inflammation  to  the  ear  by  the  Eustachian  tube  or  suppuration 
of  the  inflamed  parotid. 

The  local  discomfort  may  be  relieved  by  the  application 
of  hot  bread  or  linseed  poultices  to  the  affected  side,  and  a 
dressing  of  "  palm  oil  "  spread  on  a  piece  of  lint  and  covered 
with  some  protective  tissue  is  a  very  comfortable  application. 

Where  the  inflammation  of  the  parotid  gland  is  only 
moderately  severe,  the  patient  should  be  encouraged  to  over- 
come the  stiffness  of  the  jaw  early  in  the  day  by  gentle  passive 
and  active  attempts  to  open  the  mouth.     The  pain  and  stiffness 


Mumps.  355 

in  the  jaw  are,  of  course,  much  worse  in  the  raorniTjg  after  tlie 
night's  rest,  during  which  the  jaw  has  remained  practically 
fixed,  and  a  little  effort  on  the  part  of  the  patient  in  the  early 
morning  will  often  enable  him  to  take  food  with  a  fair  degree 
of  comfort  in  the  later  part  of  the  day.  i'or  the  sake  of  nutri- 
tion it  is  well  to  encourage  the  patient  strongly  in  all  efforts 
which  will  increase  the  mobility  of  the  jaw  and  lessen  the 
pain  during  mastication. 

Should  orchitis  occur,  the  parts  should  be  supported  by 
some  form  of  suspensory  bandage,  and  frequently  repeated  hot 
applications  should  be  made  to  the  inflamed  gland.  Glycerine 
of  belladonna,  spread  on  lint  and  covered  with  protective 
tissue,  is  a  useful  application  in  such  cases,  and  should  he 
alternated  with  bread  or  linseed  poultices. 

Should  meningitis  occur,  the  application  of  leeches  to  the 
temples  and  ice  to  the  head,  combined  with  a  free  use  of  strong 
aperients,  will  often  help  to  relieve  the  severe  symptoms  asso- 
ciated with  this  complication. 

Diet. — During  the  whole  of  the  period  of  parotid 
enlargement  the  food  should  be  fluid  or  semi-fluid,  and  tlie 
attendant  must  encourage  the  patient  to  take  sufficient  nourish- 
ment, as  in  most  cases  he  is  reluctant  to  make  the  effort  of 
eating  on  account  of  the  pain  and  stiffness  of  the  jaw. 

As  the  fever  declines,  and  the  swelling  of  the  parotid 
gland  subsides,  the  diet  may  be  increased,  and  a  full  mixed 
dietary  should  be  resumed  as  soon  as  possible. 

Epidemiology. — Epidemics  of  mumps  appear  with 
apparentl}^  no  relation  to  any  particular  season  of  the  year. 
The  disease  is  essentially  one  which  attacks  young  people,  the 
great  majority  of  those  attacked  being  between  five  and  fifteen 
years  of  age. 

When  epidemics  occur,  they  are  usually  in  connection 
with  schools,  and  they  have  frequently  arisen  in  barracks 
among  the  younger  soldiers. 

Various  micro-organisms  have  been  described  as  having 
been  isolated  from  the  parotid  and  testes,  and  as  being  prob- 
ably the  specific  causal  agent  of  the  disease.  Laveran  and 
Catrin  have  isolated  a  Gram-negative  diplococcus  from  the 
parotid,  the  testes,   and  the  blood,  and  Teissier  and  Esmain 


356  Chapter  XXI. 

have  isolated  a  Gram-negative  micrococcus  from  the  saliva 
and  the  blood,  which  they  consider  as  probably  identical  with 
the  organism  described  by  Laveran  and  Catrin.  It  is  prob- 
able, from  the  observation  of  the  disease,  that  it  is  due  to  a 
blood  infection  by  an  organism  which  finds  a  particularly 
suitable  nidus  in  the  parotid  glands,  the  testes  and  the  ovaries, 
and  it  is  perhaps  better  to  consider  the  occurrence  of  ovarian 
inflammation  and  orchitis  as  not  so  much  true  metastases  as 
simply  further  localisations  of  the  general  infection. 

The  infection  is  probably  spread  by  the  saliva,  and  it  is 
quite  possible  that  it  is  transmissable  by  intermediaries  who  do 
not  suffer  from  the  disease,  and  by  fomites. 

It  is  well  to  regard  patients  who  have  suffered  from  mumps 
as  being  definitely  infectious  for  at  least  ten  or  twelve  days 
after  the  first  occurrence  of  the  parotid  swelling,  or,  in  pro- 
longed cases  where  more  than  one  gland  or  group  of  glands 
liave  been  affected,  for  a  week  after  the  complete  subsidence  of 
the  last  sAvelling  which  has  appeared. 

Mumps  is  a  disease  which  is  quite  benign  in  character, 
and  death  is  scarcely  ever  attributable  to  the  disease  alone. 

Second  attacks  are  extremely  rare. 

Home  Prophylaxis. — Patients  suffering  from  mumps 
must  be  isolated  carefully  from  other  members  of  the  house- 
hold, and  the  attendant  in  the  sick  room  must  be  rigid  in 
wearing  an  overall  and  in  personal  cleanliness.  Although 
the  infection  of  mumps  is  probably  short  lived,  the  room  which 
the  patient  lias  occupied  should  be  disinfected  by  sulphur  or 
formalin  with  considerable  care,  and  afterwards  freely  ven- 
tilated for  some  days.  Bedclothes,  etc.,  which  have  been  in 
contact  with  the  patient  ought  to  be  disinfected  by  formalin 
or  some  carbolic  preparation  before  they  are  washed,  and  all 
coverings  of  furniture  or  other  textile  fabrics  should  be  disin- 
fected carefully,  say  by  a  formalin  spray  or  A'apour,  befoi'e 
being  put  again  into  general  circulation  in  the  household. 

Public  Health  Administration. — When  mumps  breaks  out 
in  connection  with  a  school,  all  possible  contacts  should 
Ise  carefully  observed  once  or  twice  a  day,  in  view  of  the  occur- 
Tence  of  new  cases.     Any  unexplained  pyrexia,  however  slight, 


Muvij^s.  357 

is  worthy  of  attention,  and  complaints  of  "car-ache"  and  stiff- 
ness of  the  jaws  should  always  arouse  susjiicion.  No  member 
of  the  patient's  liousehold  should  be  permitted  to  attend  school 
for  four  weeks  after  lie  has  been  isolated,  as,  altliough  the 
incubation  period  is  usually  very  much  shorter,  cases  have 
been  known  to  occur  as  late  as  twenty-seven  or  twenty-eight 
days  after  exposure  to  infection. 

The  local  authority  must  bo  prepared  to  disinfect  at  least 
the  sick  room  of  any  house  in  which  a  case  of  mumps  has 
developed. 

Mumps  is  not  a  notifiable  disease,  and  is  extremely  benign 
in  character,  so  that  no  removal  to  hospital  can  possibly  be 
insisted  upon. 


BB 


(   358   ) 


Chapter  XXII. 

RHEUMATIC    FEVER. 

Synonyms." — Acute  rheumatism . 
German  :   Flussfieber. 
French :  Le  rliumatisme  aigu. 

Definition. — Au  acute,  specific,  non-infectious  fever, 
characterised  by  inflammation  of  the  serous  membranes  of 
joints,  and  also  of  the  visceral  serous  membranes,  the  lesions 
being  commonly  multiple. 

Incubation. — As  this  disease  is  not  infectious  or  con- 
tagious, nothing  is  known  as  to  the  period  of  incubation 
which  intervenes  between  the  time  at  which  the  patient  is 
invaded  by  the  poisons  of  the  disease  and  the  appearance  of 
symptoms. 

Rash. — No  specific  rash  has  been  observed  in  this  disease, 
but  there  is  a  distinct  tendency  to  the  occurrence  of  erythe- 
mata,  both  generalised  and  confined  to  the  neighbourhood 
of  joints,  and  also  of  urticarial  eruptions  of  all  kinds  during 
the  course  of  the  fever. 

Clinical  Types. — In  a  typical  case  of  rheumatic  fever, 
the  onset  of  the  disease  is  somewhat  gradual.  The  patient 
suffers  from  pain  in  a  joint,  and  practically  at  the  same  time 
the  temperature  rises.  The  ascent  of  the  temperature  is 
usually  gradual,  and  the  fever  does  not  attain  its  maximum,  as 
a  rule,  until  about  the  end  of  the  first  week  of  illness.  The 
degree  of  pyrexia  in  very  inconstant.  In  mild  cases  the  fever 
may  not  exceed  100°  or  101°  F.,  whereas  in  severe  cases  a 
temperature  of  103°  or  104°  F.  is  quite  co'mmon  at  the  end  of 
the  first  week. 

The  pulse  in  the  early  stages  is  rapid  and  ample. 


Kheumatic  Fever.  ''>^)') 

It  is  very  common  for  putients  to  siilTor  from  sore  throat 
during  the  first  days,  at  any  late,  of  an  attack  of  rlieunialic 
fever,  and  tlie  throat  is  seen  to  be  uniformly  injected,  while 
there  is  frequently  quite  definite  enlargement  of  one  or  both 
tonsils. 

The  tongue  is  coated  at  the  back  and  centre  with  a  thick 
whitish  fur,  and  the  edges  and  tip  may  be  abnormally  red. 

The  joints  which  are  most  commonly  first  affected  in  a 
case  of  acute  rheumatism  are  the  knees  and  the  ankles.  Pain 
may  be  confined  at  first  to  only  one  joint,  and  is  not  usually 
so  intense  at  the  beginning  of  the  attack  as  to  make  the 
patient  take  to  bed,  although  he  may  suffer  considerably  from 
general  malaise  at  this  time,  and  if  the  temperature  is  taken 
it  is  found  to  be  elevated,  sometimes  highly  febrile. 
In  the  course  of  a  day  or  two,  however,  the  pain  in 
the  joint  becomes  greatly  aggravated,  and  some  pain  is  also 
felt  in  other  joints.  By  the  end  of  the  first  week  the  joint 
pain  is  most  commonly  very  severe,  and  the  joint  is  not  only 
painful  and  tender,  but  considerably  swollen.  The  swelling 
is  due  partly  to  periarticular  infiltration,  but  is  also 
due  to  the  presence  of  fluid  in  the  joint  cavity  and  in  the 
synovial  pouches.  In  a  case  even  of  moderate  severity  the 
joint  lesion  is  rarely  single,  but  one  joint  after  another  tends  to 
be  affected  in  no  regular  sequence,  pain  in  one  knee  being 
followed  by  pain  and  swelling  in  an  ankle,  and  that  again, 
perhaps,  in  a  shoulder  or  elbow,  the  wrists  and  other  joints 
becoming  in  many  cases  also  involved.  A  striking  feature 
of  the  attack  is  that  as  one  joint  becomes  painful,  the  joint 
which  has  previously  been  the  cause  of  most  suffering  becomes 
less  painful  or  even  ceases  to  be  painful  at  all,  and  that 
although  the  swelling  may  remain. 

The  face  at  the  beginning  of  an  attack  of  rheumatic  fever 
is  usually  pale,  but,  as  the  fever  increases,  it  becomes  flushed, 
and  the  patient  exhibits  most  of  the  usual  signs  of  pyrexia. 
In  rheumatic  fever,  however,  except  in  those  cases  where  the 
temperature  rises  to  definitely  hyperpyretic  levels,  the  con- 
dition of  the  skin  is  in  strong  contrast  to  that  existing  in 
the  other  acute  fevers  where  the  temperature  runs  high.  It 
is  not  harsh  and  dry,  and  does  not  feel  burning  to  the  touch. 

BB   2 


360  Chapter  XXII. 

The  patient  perspires  freely,  and  in  many  cases  suiters  from 
drenching  sweats.  Although  the  skin  generally  is  not  hot  to 
the  touch,  a  localised  elevation  of  temperature  about  the 
affected  joints  is  usually  quite  appreciable  to  the  hand. 

The  pain  in  the  affected  joints  is  of  a  peculiarly  sickening 
character;  the  patient  suffers  continuously,  and  is  quite  unable 
to  find  relief  from  pain  by  any  change  of  position.  In  a 
severe  case  the  pain  may  be  quite  bearable  when  the  joint  is 
at  rest,  but  any  movement  of  the  affected  part  induces  an 
attack  of  pain  which  is  in  many  cases  quite  excruciating. 
The  joints  are  for  the  most  part  kept  in  a  semi-flexed  posi- 
tion, and  any  attempt  to  straighten  or  flex  them  completely 
is  attended  by  great  suffering.  The  pain  seems  to  be  aggra- 
vated as  night  comes  on,  and  loss  of  sleep  consequent  on  the 
suffering  is  one  of  the  most  troublesome  features  of  an  attack 
of  rheumatic  fever. 

The  urine  is  from  the  outset  scanty  and  high  coloured, 
and  usually  deposits  a  considerable  amount  of  urates  or  uric 
acid  on  cooling. 

Although  sleeplessness  is  such  a  common  feature  of  the 
disease,  delirium,  eA^en  of  the  mildest  kind,  is  extremely  rare, 
except  in  those  cases  who  suffer  from  hyperpyrexia. 

The  odour  of  the  patient  is  rather  characteristic,  the 
sweat  having  a  curious  sour  smell  of  which  the  patient  him- 
self may  be  quite  conscious.  The  reaction  of  the  sweat  is 
usually,  in  the  earlier  stages  of  the  illness,  slightly  acid. 

The  duration  of  the  attack  is  very  variable.  In  an 
ordinary  mild  uncomplicated  case,  in  which  only  a  few  of  the 
larger  joints  have  been  attacked,  the  acute  pain  in  the  joints 
and  the  pyrexia  subside  in  about  ten  days,  especially  if  the 
salicylates  have  been  used  in  the  treatment  of  the  case, 
although  some  stiffness  and  pain  in  the  joints  on  movement 
may  remain  for  weeks  afterwards.  In  most  mild  cases  the 
convalescence  is  complete  in  three  or  four  weeks  after  the 
subsidence  of  the  symptoms. 

The  course  of  even  a  mild  case,  however,  may  be  consider- 
ably prolonged  by  the  occurrence  of  a  relapse,  which  closely 
resembles  the  original  attack,  but  is  usually  milder  and  of 
shorter   duration.     Sometimes  the  attack  is   very  short,    and 


J{heu7Tiatic  Fever.  361 

it  is  not  uncommon  to  find  that,  within  twenty-four  to  forty- 
eight  hours  after  treatment  by  salicylates  has  begun,  the  pain 
disappears  and  the  temperature  falls  to  normal.  On  the 
other  hand,  there  are  many  cases  of  a  more  severe  kind  in 
which  the  disease  endures  for  many  weeks  in  an  acute  form, 
even  thougli  no  complications  appear.  In  those  severe  pro- 
longed cases  the  joint  affection  is  not  as  a  rule  confined,  as  in 
the  minor  attacks,  to  the  larger  joints,  such  as  the  knees, 
ankles,  shoulders,  elbows,  wrists  and  hips,  but  smaller  joints 
are  affected  as  well,  the  fingers  being  peculiarly  liable  to 
attack.  The  sterno-clavicular  joint,  the  joints  of  the  toes, 
the  yertebral  articulations,  and  the  teniporo-maxillaiy  joint 
may  also  be  affected.  Whichever  be  the  joints  attacked,  the 
pain  is  in  most  cases  intense,  and  the  fleeting  character  of 
the  joint  affections  is  very  characteristic. 

In  the  majority  of  cases,  after  the  pain  and  fever  have 
passed  away,  the  joints  slowly  return  to  their  normal  condition, 
and,  beyond  a  little  stiffness  about  the  joint  itself  and  some 
weakness  in  the  muscles  which  move  it,  complete  restoration 
to  the  normal  takes  place  within  two  or  three  weeks,  or  even 
less.  A  feeling  of  stiffness  in  the  joint,  which  is  distinctly 
exaggerated  in  damp,  chilly  weather,  may  persist  in  an  inter- 
mittent way  for  a  year  or  two  after  the  attack,  although  ulti- 
mately no  gross  legion  of  the  articular  surfaces  or  the  peri- 
articular tissues  may  be  left.  In  some  cases,  however,  and 
especially  after  several  attacks  of  rheumatic  fever,  a  certain 
tTinount  of  permanent  deformity  and  stiffness  in  the  affected 
joints  may  result. 

There  is  a  grave  type  of  acute  rheumatism  in  which, 
although  the  joints  may  not  be  involved  in  any  great  number, 
the  prostration  of  the  patient  almost  from  the  outset  of  the 
illness  is  noticeably  great,  and  the  fever,  although  perhaps 
quite  moderate  in  the  early  part  of  the  disease,  tends  to  rise 
steadily  as  the  illness  progresses,  and  is  not  reduced  by  any 
treatment.  In  siich  cases  the  temperature  ultimately  reaches 
a  very  high  level,  106°  or  107°  F.  being  not  uncommon  read- 
ings. The  patient  becomes  delirious  as  the  temperature  rises, 
and  death  ensues  with  a  rising  temperature,  failing  pulse,  and 
every   sign   of   an   acute   toxaemia.     Coma    is   usually   present 


362  Chapter  XXII. 

for  some  liours  before  death.  There  is  sometimes  a  sudden 
fall  of  temperature  immediately  before  death,  but  in  many 
cases  the  temperature  is  maintained  at  a  high  level  for  some 
time  after  death,  and  in  a  few  cases  there  is  a  distinct  post- 
mortem rise.  In  other  cases  hyperpyrexia  occurs  ver}' 
suddenly  after  the  patient  has  been  seriously  ill  for  a  time, 
although  no  indication  of  an  unusually  high  temperature  may 
have  been  noticed  during  an  attack  of  some  weeks'  duration. 
In  such  cases  the  temperature  may  suddenl}^  rise  within  a 
few  hours  to  hyperpyretic  registers,  and  the  patient  becomes 
delirious  and  dies,  probably  within  forty-eight  hours.  Death 
is  not  the  invariable  result  in  those  cases  of  rheumatic  fever 
where  hyperpyrexia  has  resulted,  but  recover}^  is  excej)tional . 
The  rheumatic  fever  which  is  seen  in  childhood  is  often 
extremely  atypical,  and  while  the  disease,  with  its  multiple 
joint  lesions,  high  fever,  and  tendency  to  the  usual  compli- 
cations, is  frequently  seen  in  very  young  people,  the  primary 
manifestations  of  acute  rheumatism  in  children  may  be  very 
mild  and  on  that  account  dangerous.  One  is  quite  familiar 
with  the  occurrence  in  children  of  a  short  illness,  with  slight 
sore  throat  and  moderate  fever,  in  which  there  may  be  a  little 
pain  and  stiffness,  or  at  least  uneasiness,  in  certain  joints, 
but  which  is  not  accompanied  by  any  visible  swelling  of  the 
affected  joint,  or  tenderness  on  manipulation.  In  associa- 
tion with  this  mild  articular  affection  is  a  degree  of  aching 
in  the  muscles  or  myalgia,  which  may  be  the  principal  feature 
of  the  attack.  The  joints  themselves  in  some  cases  seem  to 
escape  entirely,  and  the  manifestations  of  the  disease  are 
confined  to  myalgia  and  inflammations  of  tendon  sheaths, 
notably,  perhaps,  in  connection  with  the  ham-string  muscles, 
and  of  the  periarticular  fibrous  structures.  But  if  in  children 
the  articular  manifestations  of  acute  rheumatism  and  pyrexia 
are  very  much  less  severe  than  in  adults,  the  disease  is 
rendered  more  dangerous  in  childhood  than  in  adult  life  by 
the  extraordinary  frequency  with  which  cardiac  complications 
attend  attacks  which,  in  respect  of  fever  and  articular  mani- 
festations, are  so  mild  as  to  be  almost  unrecognisable.  It 
would  appear  as  if  in  childhood  the  rheumatic  poison,  what- 
ever it  may  be,  tended  to  expend  itself  upon  the  heart  and 


RKeumatic  Fever.  363 

pericardium,  leavirif^  the  joints  largely  unaftectc^d,  while  as 
age  advances,  tlie  joint  tissues  become  more  vulnerable  to 
the  poison,  and  the  heart  and  pericardium  much  less  easily 
affected,  so  that  after  the  age  of  pu})erty,  or,  at  any  rate,  after 
the  age  of  twenty,  articular  manifestations  lend  io  be  more 
severe  than  in  childhood,  but  the  occurrence  of  cardiac  cf)m- 
plications  is  much  less  frequent. 

Anmmia  is  a  striking  feature  of  most  cases  of  acute  rheu- 
matism. After  the  first  week  of  illness  the  patient  becomes 
markedly  pallid,  the  pallor  being  noticeable  not  only  in  the 
skin,  but  in  the  mucous  membrane  of  the  conjunctiva,  lips 
and  mouth.  In  association  with  this  anaemia,  the  pulse  is 
soft  and  the  blood  pressure  tends  to  be  low.  There  is  a  con- 
siderable reduction  in  the  number  of  the  red  cells,  and  there 
miay  be  a  slight  increase  in  the  number  of  white  cells ;  the 
percentage  of  haemoglobin  is  reduced.  Where  an  attack 
is  short,  and  especially  if  it  is  uncomplicated  by  any  serious 
cardiac  or  pulmonary  lesion,  the  red  cells  usuallj^  increase 
rapidly  in  number  during  convalescence,  but  in  protracted 
cases  the  anaemia  may  persist  for  long  after  all  signs  of  rheu- 
matism have  passed  away. 

Second  and  even  third  attacks  of  rheumatic  fever  are 
very  common,  and  a  patient  who  has  weathered  a  first  attack 
without  any  cardiac  lesion  may  develop  endocarditis  in  a 
later  attack.  In  fact,  endocarditis  is  not  so  common  in  first 
attacks  as  in  second  or  subsequent  attacks. 

Complications. — The  complications  of  rheumatic  fever 
arise  mainly  in  connection  with  the  heart  and  the  lungs. 
Death  occurs  in  uncomplicated  cases  only  when  hyperpyrexia 
occurs  as  a  terminal  phase,  without  any  visible  gross  lesion  of 
the  cerebro-spinal  system,  and  it  is  in  the  possibility  of  the 
occurrence  of  some  of  the  graver  complications  that  the  main 
danger  of  an  attack  of  acute  rheumatism  lies. 

While  cardiac  affections  are  usually  described  as  com- 
plications of  rheumatic  fever,  the  description  is  hardly  a 
correct  one.  It  may  be  said  more  truly  Ihat  they  are  ordinary 
and  direct  manifestations  of  the  disease,  and,  as  certain  joints 
may  escape  in  an  attack,  and  certain  others  be  affected,  so  in 


364  Chapter  XXII. 

one  attack  the  myocardium,   tlie  endocardium,   or  the  peri- 
cardium may  be  affected,  while  in  another  they  may  escape. 

Myocarditis,  endocarditis  and  pericarditis  may  occur 
either  singly  or  together  in  acute  rheumatism. 

Of  these  affections  endocarditis  is  by  far  the  most 
common,  and  occurs  very  frequently  alone.  It  is  difficult  to 
say  accurately  when  endocarditis  appears,  since  its  onset  is 
insidious,  and  is  not  associated  with  any  pain,  or,  if  the 
patient  is  at  rest,  with  any  cardiac  disturbance.  It  is  only 
b}^  frequent  and  careful  auscultation  of  the  heart  that  the 
presence  of  endocarditis  can  be  detected,  and  then  only  on  the 
occurrence  of  a  cardiac  murmur.  The  mitral  valve  is  the 
most  commonly  affected,  and  while  the  aortic  valve  is  some- 
times affected  alone,  an  aortic  lesion  of  rheumatic  origin  is 
usually  found  in  conjunction  with  an  affection  of  the  mitral 
valve.  The  tricuspid  valve  may  also  be  affected,  again  usually 
in  conjunction  with  the  mitral,  and  in  children  the  pulmonic 
valve  is  sometimes  attacked,  although  very  rarely.  It  has 
been  said  that  if  no  cardiac  murmur  is  detected  after  careful 
examination  during  the  first  ten  days  of  an  attack,  it  means 
in  a  large  majority  of  cases  that  the  endocardium  has  escaped. 
In  certain  cases,  however,  an  acute  endocarditis  appearing  in 
the  course  of  rheumatic  fever  does  not  produce  an  endocardial 
murmur  for  some  time.  It  would  appear  that  in  those  cases 
a  deformity  of  the  valve  sufficient  to  produce  a  murmur  was 
not  produced  during  the  acute  stage  of  the  endocarditis,  but 
occurred  only  on  the  contraction  of  the  previously  inflamed 
valve.  In  certain  cases,  too,  it  seems  that  the  detection  of 
a  systolic  bruit  in  the  mitral  area  during  the  acute  stage  of 
the  attack  does  not  necessarily  mean  the  existence  of  an  endo- 
carditis, since  such  murmurs  have  been  known  to  be  present 
in  the  early  stage  of  an  attack  of  rheumatic  fever,  but  have 
disappeared  as  convalescence  was  established,  nor  were  they 
again  detected,  although  the  patient  was  under  careful 
medical  supervision  for  many  decades  thereafter. 

Pericarditis  is  another  complication  which  is  both 
frequent  and  dangerous.  It  appears  at  any  time  during  the 
course  of  the  fever,  and  may  be  present  without  giving  rise 
to  any  symptoms  referable  to  the  heart,  so  that  only  careful 


Rheuiiuiiic  Fever.  365 

auscultation  of  the  prsecordium  reveals  tlie  presence  of  any 
lesion.  Pericarditis  usually  appears  in  those  cases  wlien  the 
joint  affection  has  been  extensive  and  severe.  The  symptoms- 
which  attend  its  onset  are  very  variable.  In  some  cases  the 
patient  suffers  from  a  considerable  amount  of  pain  and  a 
sense  of  oppression  in  the  pra>cordial  region,  and  the  pain  is 
often  increased  by  pressure  of  the  hand  or  of  tlie  stetho- 
scope. The  pulse  rate  is  frequently  accelerated,  even  before 
any  friction  sound  is  apparent.  The  friction  sound  is  most 
commonly  soft  and  not  very  loud,  and  its  most  frequent  situa- 
tion is  towards  the  base  of  the  heart,  quite  near  the 
sternal  margin,  rriction  sounds  are  not  always  present  in 
cases  of  rheumatic  pericarditis.  Clinically,  the  first  sign  of 
the  occurrence  of  pericarditis  may  be  an  extension  of  the 
prsecordial  area  of  dullness.  This  extension  may  be  general, 
involving  the  left,  right  and  upper  borders  of  the  preecordial 
area  of  dullness,  or  it  may  involve  the  right  or  the  left  with 
the  upper  border,  or  may  be  in  an  upward  direction  alone. 
It  is  not  usual  to  find  an  extension  only  to  the  left  or  to  the 
right,  and  this  point  is  of  some  importance  in  a  differential 
diagnosis  between  a  pericarditis  without  pain  and  without 
apparent  friction,  and  a  dilatation  of  one  or  other  side  of  the 
heart.  The  extension  of  the  praecordial  dullness  is  due  to 
effusion  into  the  pericardium.  The  eft'usion  in  most  cases 
is  due  to  "  organisable  lymph,"  and  may  be  very  large.  A 
mixed  effusion  of  lymph  and  serum  is  also  frequently  met 
vrith,  but  a  purely  serous  effusion  is  much  less  common. 

The  duration  of  an  attack  of  pericarditis  is  very  variable. 
In  some  attacks  nothing  more  is  observed  than  a  slight  amount 
of  soft  friction  rub,  which  appears  and  disappears  within  a 
few  days,  without  any  visible  extension  of  the  prsecordial  area 
of  dullness.  In  other  cases  where  a  large  effusion  occurs  the 
prsecordial  area  of  dullness  may  not  resume  its  normal  propor- 
tions for  many  days  or  even  weeks,  and  after  the  subsidence 
of  the  effusion  a  certain  amount  of  friction  may  persist  for 
some  time  longer. 

Pericarditis,  when  it  occurs  alone,  unaccompanied  by 
endocarditis,  is  a  grave  coauplication,  but  is  not  usually  fatal, 
and    after    an    attack    the    heart    may    recover    completely. 


366  Chapter  XXII. 

remaining  normal  to  physical  examination  and  giving  rise 
to  no  trouble  during  the  patient's  after-life,  even  though 
it  is  probable  from  the  extent  and  character  of  the  pericardial 
effusion  that  some  adhesion  between  the  surfaces  of  the  peri- 
cardium is  a  certain  consequence.  It  would  appear  that  the 
surfaces  of  the  pericardium  may  be  adherent  without  giving 
rise  to  any  after-effects,  unless  these  adhesions  are  very  dense 
and  massive,  or  unless  the  parietal  pericardium  has  also 
become  adherent  to  the  pleura  or  the  chest  wall. 

These  remarks  apply  mainly  to  the  rheumatic  pericarditis 
of  adults.  In  children  pericarditis  is  a  very  serious  condition. 
During  an  attack  the  child  is  restless,  and  the  pulse  is  very 
rapid,  although  the  degree  of  fever  at  the  time  may  be  quite 
moderate.  As  in  adults,  the  pericarditis  may  proceed  with 
or  without  a  noticeable  effusion  into  the  pericardium,  but 
even  when  all  signs  and  symptoms  of  the  attack  have  passed, 
the  child  is  not  yet  out  of  danger.  The  condition  tends  to 
recur,  and  may  recur  many  times.  As  a  rule  after  each 
recurrence  the  prsecordial  area  of  dullness  remains  increased 
beyond  the  normal,  the  heart  sounds  grow  feeble  and  muffled, 
and  signs  of  cardiac  failure,  such  as  dropsy,  dyspnoea  and 
cyanosis,  develop.  The  increase  in  the  size  of  the  prsecordial 
dullness  is  probably  due  both  to  enlargement  of  the  heart 
itself  and  to  the  presence  of  enormously  thickened  pericardial 
layers,  which  are  adherent  to  each  other.  Children  frequently 
■die  as  a  result  of  this  process  within  a  comparatively  short 
time,  and  even  in  those  who  make  a  temporary  recovery,  it 
is  often  apparent  that  the  nutrition  of  the  part  is  seriously 
interfered  with  by  the  pericardial  lesion,  and  the  general 
nutrition  of  the  patient  suffers  in  proportion. 

Sometimes  the  inflammatory  process  spreads  from  the 
pericardium  to  the  pleura  and  to  the  mediastinum,  and  the 
miediastinum,  pleura,  and  pericardium  become  adherent  and 
connected  by  a  mass  of  fibrous  tissue.  This  condition  is 
called  "indurative  mediastino-pericarditis."  When  the 
condition  exists,  an  area  of  dullness  extends  upwards  in  the 
region  of  the  middle  and  upper  parts  of  the  sternum,  and 
there  is  evidence  of  great  respiratory  and  cardiac  difficulty. 
The  condition  is  not  common,  but  has  been  noted  by  many 


Rliev/matic  Fever.  367 

observers.  Sometimes  the  fibrous  growth  presses  upon  or 
constricts  the  great  veins  at  the  base  of  the  heart,  and  a 
passive  congestion  of  the  liver,  ascites,  hypostatic  congestion 
of  the  lungs,  cyanosis,  shortness  of  breath  and  anasarca 
result. 

Myocarditis  usually  accompanies  pericarditis  and  endo- 
carditis, but  tliere  is  some  clinical  evidence  to  show  that  an 
acute  myocarditis  may  occur  by  itself  as  the  result  of  the 
action  on  the  cardiac  muscle  of  the  rheumatic  poison.  Lees 
has  demonstrated  liow  frequently  the  lieart  in  rheumatism 
may  be  enlarged  to  the  right  or  left,  even  where  there  is  no 
evidence  at  the  time  of  any  pericarditis  or  endocarditis,  and 
it  seems  only  reasonable  to  suppose  that  in  such  cases,  where 
even  after  the  lapse  of  time  no  cardiac  murmur  has  become 
audible  which  Avould  suggest  the  presence  of  a  valvular  lesiou , 
the  dilatation  of  the  heart  has  been  due  to  a  primary  affection 
of  the  myocardium.  An  acute  primary  myocarditis  of  this 
kind  seems  capable  of  complete  resolution. 

Pneumonia  may  occur  as  a  complication  of  acute  rheu- 
matism, and  differs  considerably  in  type  from  acute  lobar 
pneumonia.  The  amount  of  consolidation  present  varies  very 
much  in  different  cases.  In  some  it  is  quite  large,  while  in 
others  it  is  very  small  indeed,  and  the  main  lesion  may  be 
an  extensive  and  acute  congestion  of  the  lower  parts  of  the 
lung  without  much  definite  consolidation.  The  aff'ection  is 
not  usually  painful,  and  although  the  respiration  rate  may 
be  considerably  increased,  cough  and  expectoration  are  not 
as  a  rule  troublesome.  The  pneumonia,  in  fact,  tends  to  be 
rather  of  a  low  and  incomplete  type,  and  may  persist  for  a 
long  time,  and  be  very  slow  in  resolution.  The  amount  of 
fever  accompanying  such  an  attack  may  be  considerable,  and 
the  temperature  usually  falls  not  by  crisis,  but  by  a  rather 
slow  lysis.  Pericarditis  and  pneumonia  sometimes  occur 
together,  and  the  combination  is  a  very  deadly  one. 

Pleurisy  is  sometimes  met  with,  and  may  go  on  to  effu- 
sion.    The  pleural  effusion  occasionally  becomes  purulent. 

A  simple  hronchial  catarrh  sometimes  occurs,  but  is  less 
common  than  either  pneumonia  or  pleurisy. 


368  Chapter  XXII. 

To/isilUtis,  although  iisuall}^  found  precediug  an  attack 
of  acute  rlieuuiatism,  uiay  occur  during"  the  course  of  the 
fever. 

Rheumatic  nodides,  small  fibrous  swellings  which  are 
mostly  subcutaneous,  but  which  are  also  found  deeply  seated 
between  the  muscles,  are  met  Avith  frequently  during  the 
course  of  rheumatic  fever,  particularly  in  children.  There 
seems  little  doubt  that  these  nodules  appear  in  children  in 
association  with  endocarditis  and  pericarditis,  but  they  are 
sometimes  seen  even  in  children  in  cases  where  no  cardiac 
lesion  exists.  In  association  with  endocarditis  they  indicate 
a  grave  condition,  and  adversely  influence  prognosis.  In 
adults,  however,  their  occurrence  seems  to  have  no  particular 
bearing  on  prognosis,  and  they  have  not  been  specially  noticed 
in  those  cases  which  develop  a  cardiac  lesion.  They  are 
found  in  the  scalp,  behind  the  ears,  at  the  back  of  the  neck, 
on  the  back,  the  gluteal  region,  the  wrists,  ankles,  and  about 
the  knees.  They  are  painful,  and  very  often  distinctly  tender 
on  pressure.  They  are  not  very  sharply  defined,  and  are 
often  so  small  as  to  be  only  discoverable  on  careful  exaanina- 
tion.  Sometimes,  however,  they  are  of  considerable  size, 
about  as  large  as  a  hazel  nut  or  an  almond.  These  fibrous 
nodules  persist  in  many  cases  for  only  a  few  days,  but  in 
some  cases  they  are  still  evident  all  through  the  period  of 
convalescence,  and  may  give  rise  to  considerable  discomfort 
and  pain. 

Erythema  nodosum  is  sometimes  seen  even  during  the 
acute  stage  of  the  fever. 

Diagnosis. — Excej^t  in  young  children,  and  in  mild 
attacks  where  the  joint  affection  is  single,  the  diagnosis  of 
acute  rheumatic  fever  presents,  as  a  rule,  but  little  difficulty. 
In  a  typical  case  the  gradual  onset  of  the  attack,  the  muHiple 
and  fleeting  character  of  the  joint  lesions,  the  condition  of 
the  skin,  the  profuse  sweating,  and  the  generally  pallid  face, 
go  to  form  a  picture  that  is  not  easily  mistaken  for  anything 
else. 

In  young  children,  however,  the  joint  affections  being 
so  slight  as   almost  to  escape  notice,   the   general   aching  of 


/^Jirumafir  Fever.  369 

muscles  and  slight  fever  may  be  attributed  cniti rely  to  tlie 
inflammation  of  tlie  tonsils,  wbicJi  is  so  often  present.  Wliere 
tlie  joint  lesion  is  single,  tlie  condition  is  often  considered 
to  be  traumatic,  even  tliougli  no  definite  injury  bas  been 
known,  particularly  as  sucb  a  condition  usually  occurs  in 
children  of  school  age  and  in  adolescents,  who  are,  by  nature 
of  their  amusements,  specially  liable  to  trauma. 

There  are  three  conditions  wliicb  may  very  closely 
resemble  a  case  of  true  rheumatic  fever,  namel}-,  a  certain 
type  of  multiple  artliritis,  osteoTnyelitis,  and  a  pya-viia  which 
arises  without  any  very  ajiparent  or  definite  superficial  lesion. 

One  sees  occasionally  a  patient  sent  to  hospital  as  suffering 
from  acute  rheumatism  where  the  real  lesion  is  an  acute 
osteomyelitis  of  one  of  the  long  bones,  such  as  the  femur  or 
the  tibia.  In  such  conditions  there  is  very  often  considerable 
SAvelling  of  the  knee  or  the  ankle,  or  some  other  joint,  and 
the  skin  in  the  neighbourhood  of  the  joint  is  frequently 
reddened,  and  there  is  also  swelling  of  the  periarticular 
tissues.  The  pain  and  tenderness  are  scarcelj^  so  acute  as 
in  rheumatic  fever,  and  the  swelling  of  the  limb  is  usually 
quite  definitely  oedematous,  and  is  not  confined  to  the  neigh- 
bourhood of  the  joint,  but  extends  up  the  limb.  The  defi- 
nitely single  character  of  the  lesion,  combined  with  constitu- 
tional symptoms  which  are  usually  severe  and  a  temperature 
which  is  commonly  of  the  hectic  type,  serves  to  make  the 
differentiation  of  such  a  condition  a  comparatively  easy 
matter. 

In  the  case,  however,  of  certain  types  of  multiple 
artliritis  the  differentiation  from  acute  rheumatism  is  not 
always  easy.  A  definite  history  of  gonorrhoea  or  the  discovery 
of  tlie  gonococcus  in  tlie  urine  of  an  obstinately  uncommuni- 
cative person,  often  betrays  the  origin  of  the  attack.  But 
apart  from  any  specific  form  of  arthritis  there  are  certain 
cases  of  multiple  arthritis  which  are  not  acute  rheumatism, 
but  may  be  very  easily  mistaken  for  it.  Particularly  in 
women,  and  more  especially  among  women  who  have  been 
weakened  by  child-birth  and  certain  of  its  accidental  after- 
effects, a  multiple  osteo-arthritis  may  begin  by  acute  swelling 
with  pain  and  redness  of  certain  joints,  accompanied  by  some 


370  Chaper  XXI 1. 

fever.  On  tlie  first  occurrence  of  such  an  attack  tlie  diagnosis 
of  acute  rheumatism  may  be  quite  justifiably  made,  and  it 
is  only  on  the  occurrence  of  subsequent  attacks  with  resulting 
typical  deformity  that  it  becomes  apparent  that  the  original 
diagnosis  was  wrong.  The  fact  of  such  a  case  being  asso- 
ciated with  a  definite  focus  of  suppuration,  like  an  endometritis 
or  pyorrhoea  alveolaris,  sometimes  helps  to  clear  up  the  diag- 
nosis, especially'-  if  on  the  removal  of  such  suppurative  foci 
the  attacks  cease.  The  fever  in  such  cases  is  usually  moderate, 
and  the  joint  lesion  is  out  of  all  proportion  to  the  slight 
amount  of  constitutional  disturbance.  The  fact  that  a  case 
which  closely  resembles  a  typical  attack  of  acute  rheumatism 
does  not  in  any  way  yield  to  treatment  by  the  salicylates 
should  always  arouse  the  suspicion  that  it  is  really  an  early 
manifestation  of  a  multiple  osteo-arthritis. 

In  'pycemia  of  obscure  origin  the  joint  affections  may  be 
multiple,  but  the  pain  and  swelling  in  the  affected  joints  show 
none  of  the  fleeting  characters  which  are  so  typical  of  the 
lesions  in  rheumatic  fever.  The  joint,  once  affected,  remains 
swollen,  reddened,  painful  and  tender,  while  a  hectic  type  of 
fever,  accompanied  by  frequent  rigors,  should  make  it  quite 
apparent  after  a  short  period  of  observation  that  the  disease 
is  something  other  than  acute  rheumatism.  Rigors,  in  the 
case  of  rheumatic  fever,  are  of  the  rarest  occurrence,  and  the 
fever  is  practically  never  of  a  hectic  type. 

The  early  stages  of  an  acute  ulcerative  endocarditis  may 
closely  resemble  an  attack  of  rheumatic  fever,  more  particu- 
larly as  a  large  number  of  those  patients  who  suffer  from  an 
acute  ulcerative  endocarditis  have  previously  been  the  victims 
of  acute  rheumatism.  Again,  however,  the  hectic  type  of  the 
fever  helps  one  to  a  differential  diagnosis,  and  the  spleen  in 
such  cases  is  often  enlarged  as  the  result  of  repeated  embolism. 
Albumin  and  blood  are  frequently  met  with  in  the  urine  of 
such  patients,  also  secondary  to  the  occurrence  of  embolism, 
and,  although  a  certain  amount  of  pain  and  swelling  in  joints 
is  not  uncommon  in  the  course  of  ulcerative  endocarditis,  the 
course  of  the  disease  seldom  leaves  the  diagnosis  long  in 
question. 


RheuTTiatic  Fever.  371 

A  first  attack  of  gout  in  a  young  subject,  especially  if 
it  occurs  in  a  country  where  gout  is  not  common,  is  frequently 
mistaken  for  acute  rheumatism,  but  in  siich  a  case  the  absence 
of  fever,  the  presence  of  gastro-intestinal  symptoms,  a  careful 
study  of  the  family  history,  and  the  absence  of  any  cardiac 
lesion,  are  usually  sufficient  to  clear  up  the  diagnosis. 

Treatment. — All  patients  suffering  from  rheumatic  fever 
must  be  kept  in  bed  and  absolutely  at  rest.  It  is  of  the 
utmost  importance,  in  view  of  the  possible  occurrence  of  car- 
diac lesions,  that,  where  there  is  the  slightest  suspicion  of  a 
patient  suffering  from  rheumatic  fever,  he  should  be  kept 
away  from  all  danger  of  surface  chill  and  should  not  be 
permitted  to  exert  himself  at  all.  Once  a  patient  is  in  bed, 
he  should  not  be  allowed  to  get  up  for  any  purpose. 

The  affected  joints  should  be  wrapped  in  cotton  wool, 
kept  in  place  by  a  light  dumette  or  flannel  bandage.  The 
patient's  clothing  should  be  of  flannel,  and  of  such  a  con- 
struction as  to  be  easy  of  change,  disturbing  the  position  of 
the  patient  as  little  as  possible.  This  is  of  importance,  as, 
on  account  of  the  excessive  perspiration,  frequent  change  of 
the  patient's  clothing  must  be  made. 

Various  local  applications  to  the  affected  joints  have 
been  employed,  such  as  blisters,  cold  compresses,  and  ice 
packs,  and  the  injection  of  a  solution  of  carbolic  acid  into 
the  joint  has  been  recommended  by  some.  A  form  of  surgical 
treatment  which  has  been  urged  by  a  few,  is  the  making  of 
an  incision  by  the  side  of  the  affected  joint  immediately  on 
the  occurrence  of  the  pain  and  swelling.  All  local  applica- 
tions, however,  seem  to  have  little  effect  on  the  course  of  the 
illness,  and  for  the  relief  of  pain  the  application  of  cotton 
wool  and  flannel,  or  a  compress  medicated  with  glycerine  and 
belladonna,  usuallj'-  meets  the  needs  of  the  case,  and  mis- 
chievous local  interference  is  to  be  strongly  deprecated. 

The  two  forms  of  general  treatment  which  have  had  the 
greatest  vogue  in  our  own  time  are  the  alkaline  treatvient  and 
treatment  by  the  salicylates. 

The  alkaline  treatment  consists  in  the  giving  of  large 
doses  of  the  salts  of  potash  at  frequent  intervals  until  the 
fever  subsides  and  for  some  time  thereafter.     This  form  of 


372  Chapter  XXI i. 

treatment  seems  to  have  little  eltect  on  pain,  and  when  it  is 
employed,  pain  must  be  relieved  by  the  hypodermic  injection 
of  morphine.  Morphine  is,  as  a  rule,  well  tolerated  by  such 
patients,  especially  if  there  be  no  pulmonary  lesion,  since  one 
of  the  effects  of  the  alkaline  treatment  is  to  induce  a  copious 
diuresis,  which  encourages  the  elimination  of  the  drug.  One 
of  the  great  advantages  of  the  alkaline  treatment  is  that  it 
exerts  no  unfavourable  influence  on  the  heart;  in  fact,  its 
gently  depressing  action  on  that  organ  rather  discourages  than 
favours  the  occurrence  of  endocarditis  and  pericarditis. 

At  the  present  day  the  favourite  treatment  for  acute 
rheumatism  is  by  the  salicylates,  particularly  the  salicylate 
of  soda.  Salicin  and  salicylic  acid  had  at  one  time  a  con- 
:siderable  vogue,  but  their  effect  on  the  stomach  was  not 
pleasant,  and  they  were  soon  replaced  in  this  country  by 
salicylate  of  soda.  Many  observers  have  noted  bad  results  as 
following  on  the  employment  of  the  salicylates,  but  it  would 
seem  as  if  certain  of  these  bad  results  were  due  to  impurities 
in  the  drug,  and  certain  others  to  excessive  dosage  and  too 
prolonged  administration.  The  efficacy  of  salicylate  of  soda 
seems  to  be  increased  if  it  is  given  in  combination  with  the 
bi-carbonate  of  soda  or  the  bi-carbonate  of  potash.  It  is 
nisual  to  begin  with  a  dose  of  10  to  20  grs.  of  sodium  salicylate, 
■combined  with  equal  quantities  of  bi-carbonate  of  soda  or 
potash,  repeating  this  dose  every  two  hours  until  pain  is 
xelieved  and  fever  is  lessened,  or  until  slight  ringing  in  the 
ears  and  a  tendency  on  the  part  of  the  patient  to  wander 
indicate  that  the  limits  of  toleration  are  being  reached.  The 
-quantity  of  the  drug  should  be  reduced  as  qiiickly  as  possible, 
and  as  pain  and  swelling  of  the  joints  lessen,  the  frequency  of 
-the  dose  should  be  reduced  so  that  the  drug  is  given  only 
every  four  hours.  After  the  pain  and  fever  have  gone,  the 
drug  may  be  given  twice  daily  for  some  days  and  then  dis- 
continued. The  occurrence  of  a  pericardial  or  endocardial 
lesion  is  by  some  taken  as  an  indication  that  the  use  of  the 
salicylates  should  be  stopped,  but  if,  even  in  association  with 
these  complications,  the  heart  rate  is  not  excessive  and  the 
blood  pressure  is  kept  up  to  a  fairly  average  height,  a  modifi- 
.cation  of  tlie  dose  is  usually  sufficient. 


Rheumatic  Fever.  373 

While  the  salicylates  are  beinf,^  givc'n  it  is  well  to  observe 
the  behaviour  oi:  tlie  pulse  very  carefully.  Jf  the  pulse  rate 
teuds  to  increase  out  of  proportion  to  the  temperature,  and 
if  the  blood  pressure  is  diminished,  the  dosage  should  be 
reduced,  even  thougli  there  is  no  buzzing-  in  tl)e  ears  with 
a  tendency  to  deliriuin,  or  any  evidence  of  a  cardiac  lesion. 

Similarly,  during-  convalescence,  while  it  is  well  to  keep 
up  the  action  of  the  salicylates  for,  say,  a  week  or  ten  days 
at  least  after  the  subsidence  of  the  fever,  the  dose  must  be 
reg^ulated  by  an  equalh'-  careful  consideration  of  the  pulse 
and  the  cardiac  strength. 

If  some  stiffness  in  the  joints  remains  after  the  fever 
has  subsided,  it  is  good  practice  to  give  the  patient  each 
morning  before  breakfast  30  to  60  grs.  of  the  citrate  of  potasli 
in  a  good  draught  of  water.  This  may  be  continued  for  a 
week  or  two  after  the  treatment  by  the  salicylates  has  been 
stopped. 

In  many  cases  one  of  the  most  troublesome  features  of  a 
case  of  rheumatic  fever  during  convalescence  is  a  continua- 
tion, and  sometimes  an  exaggeration,  of  the  anaemia  w^hich 
has  been  present  during  the  febrile  period  of  the  disease. 
When  anaemia  persists  in  convalescence  an  examination  of 
the  blood  shows  as  a  rule  a  different  picture  from  that  usually 
obtained  during  the  acute  period  of  the  attack.  The  number 
of  red  cells  may  return  practically  to  normal  and  there  may 
be  no  increase  of  white  cells,  but  the  main  feature  of  the 
anaemia  is  a  persistent  diminution  in  the  quantity  of 
haemoglobin.  The  anaemia  thus  assumes  a  definitely 
chlorotic  type.  When  this  occurs  the  patient  should 
be  put  upon  steady  doses  of  iron,  combined  perhaps  with  a 
little  arsenic.  iilthough  the  patient  is  taking  iron  there  is 
no  reason  to  intermit  the  doses  of  citrate  of  potash  which  he 
may  be  getting  at  the  time.  Patients  who  are  suffering  from 
this  chlorotic  type  of  anaemia  during  convalescence  are  often 
extremely  intolerant  of  iron,  and  even  the  scale  preparations 
may  give  rise  to  some  gastric  disturbance.  A  preparation 
w^hich  is  well  tolerated  by  many  patients  who  are  refractory 
to     other     salts     of     iron     is     the     algide,     which     is     sold 


CO 


374  Chapter  XXII. 

under  the  name  of  "  Algiron."  Tliis  preparation  may  be 
useful  in  cases  M'liicli  have  shown  a  tendency  to  intolerance 
of  the  drug.  It  is  not  wise  to  administer  iron  during  the 
acute  stage  of  the  fever. 

Constl'pation  is  the  rule  in  rlieumatic  fever,  and  if  the 
bowels  are  constipated  and  the  tongue  coated,  a  moderate 
dose  of  calomel,  followed  by  some  sodium  sulphate  or  mag- 
nesium sulphate  in  hot  water,  should  be  given.  Instead  of 
calomel,  a  pill  containing  pil.  hydrag.  2  grs.,  pil. 
colocinth  et  hyoscyami.  3  grs.,  and  estr.  belladonnse,  A 
gr.,  may  be  given.  It  is  not  wise  to  push  the  action  of 
mercurials  in  acute  rheumatism.  One  free  purge  at  the 
beginning  of  treatment  by  the  salicylates  is  usually  suffi- 
cient, and  if  the  bowels  tend  to  be  constipated  thereafter, 
some  more  simple  aperient  may  be  used. 

The  fever  in  acute  rheumatism  is  rarely  so  high  as  to 
call  for  any  treatment  other  than  tepid  sponging  of  the 
body  and  limbs,  but  when  hy  per 'pyrexia  occurs  some  special 
form  of  treatment  is  necessary.  On  no  account  must  anti- 
pyretic drugs  be  used,  but  ice  compresses,  ice  packs,  and 
rubbing  the  body  with  blocks  of  ice  may  be  of  considerable 
service  if  the  fever  has  reached  dangerous  heights.  Perhaps 
the  best  method  of  dealing  with  hyperpyrexia  in  rheumatic 
fever  is  to  employ  the  cold  bath.  The  temperature  of  the 
bath  before  the  patient  is  put  into  it  should  be  about  65*^ 
F.,  and  the  water  may  be  kept  cool  by  the  introduction 
of  ice,  as  it  becomes  heated  by  the  patient,  so  that  the  bath 
is  kept  steadily  at  a  temperature  of  about  60°  F.  The  patient 
should  remain  in  the  bath  until  his  temperature  has  fallen 
some  3°  or  4P  P.,  but  if,  even  after  the  temperature  has  fallen 
only  slightly,  the  patient  shows  a  tendency  to  shiver  or. to 
become  at  all  exhausted,  he  should  be  immediately  taken  out 
of  the  bath  and  put  back  to  bed.  The  number  and  frequency 
of  the  baths  must  be  regulated  by  the  degree  of  persistence 
of  the  hyperpyrexia.  In  many  cases  the  cold  bath  is  followed 
by  a  tendency  to  collapse,  and  on  the  slightest  suggestion  of 
collapse  stimulants  should  be  administered  freely,  and  if  the 
extremities  remain  cold  and  any  cyanosis  appears,  hot  bottles 
should    be    applied    to    the    feet    and    hot    cloths    over    the 


Rheumatic  Fever.  375 

prsecordium.  The  possibility  of  collapse  occurring  in  connec- 
tion with  the  oold  bath  treatment  makes  it  unwise  to  treat  any- 
one in  this  way  who  is  suffering  from  pericarditis,  endocarditis 
or  pneumonia.  It  is  true  that  many  cases  complicated  by  a 
cardiac  or  pulmonary  lesion  stand  the  cold  bath  treatment 
well,  but,  seeing  that  one  has  little  indication  beforehand  as 
to  what  patient  is  likely  to  show  a  tendency  to  collapse  under 
this  treatment,  it  is  erring  on  the  safe  side  to  avoid  treating 
in  this  way  all  patients  who  are  weighted  with  a  pulmonary 
or  cardiac  complication.  One  must  not,  however,  be  too 
dogmatic  on  this  point,  since  the  actual  danger  of  hyper- 
pyrexia may  be,  in  such  cases,  greater  than  any  possible 
danger  connected  with  the  cold  bath  treatment. 

Endocarditis  calls  for  no  special  treatment  except  pro- 
longation of  absolute  rest  beyond  the  limit  common  in  uncom- 
plicated cases,  save  that  in  all  probability  the  dose  of  the 
salicylates  must  be  modified  earlier  than  usual. 

The  treatment  of  'pericarditis  similarly  calls  for  prolonged 
absolute  rest,  and  possibly  a  reduction  in  the  doses  of  the 
salicylates.  Beyond  this  all  treatment  must  be  symptomatic, 
and  directed  towards  the  relief  of  discomfort,  praecordial 
oppression  and  pain.  The  application  of  leeches  or  a  blister 
to  the  prsecordium  is  often  of  great  service  in  the  relief  of 
pain,  but  these  extremer  measures  need  not  be  resorted  to 
until  the  application  of  heat,  combined  with  the  glycerine  of 
belladonna,  has  been  found  to  bring  no  relief.  Some  patients 
are  relieved  by  the  application  of  ice  to  the  prsecordium,  but 
others  seem  to  be  fretted  and  rendered  uncomfortable  by  any 
cold  applications.  If  the  patient  is  restless  and  suffers  from 
dyspnoea,  a  little  opium  or  morphine  may  be  given  with 
benefit. 

Pneumonia,  pleurisy  and  bronchitis  may  call  for  special 
treatment  along  the  lines  usually  adopted  in  these  diseases. 

Tonsillitis  requires  no  treatment  beyond  the  administra- 
tion of  the  salicylates,  and  attention  to  the  cleanliness  of  the 
throat  and  mouth. 

The  treatment  of  rheuinatic  nodules  depends  very  much 
upon  how  painful  they  are  and  how  long  they  tend  to  persist 

CC    2 


376  CJiapfer  XXII. 

after  the  ucuter  stage  has  passed.  If  in  the  acute  stage  of  the 
fever  they  are  associated  Avith  much  pain,  a  dressing,  com- 
posed of  an  ointment  containing  Qiii.  of  methyl  salicylate  to 
51.  of  lanoline  spread  on  a  piece  of  lint  and  covered  with  pro- 
tective tissue,  Avill  often  prove  very  efficacious.  Where,  how- 
ever, at  this  stage  of  the  illness  they  are  not  very  painful, 
no  special  treatment  is  required.  As  they  often  persist 
in  a  somewhat  chronic  form  after  the  attack  of  acute  rheu- 
matism has  passed  away,  and  as  under  these  circumstances 
the}'  are  apt  to  cause  annoyance  by  being  tender  on  pressure 
and  producing  a  certain  amount  of  stiffness  and  limitation 
of  movement  in  certain  parts,  they  sometimes  require  treat- 
ment directed  definitely  towards  their  removal.  Where  the 
rheumatic  nodules  tend  to  persist  in  this  chronic  way  small 
doses  of  iodide  of  potash,  say  3  to  5  grs.,  ma}^  be  given  thrice 
daily,  and  massage  should  be  used  to  assist  in  the  dissipation 
of  the  nodules.  Where  they  are  superficial,  the  massage  does 
not  usually  need  to  be  severe,  and  it  is  better  to  treat  such 
cases  by  rubbing  gently  into  the  affected  areas  some  prepara- 
tion like  iodex  ointment  twice  in  the  day.  If  tlie  nodules  are 
deeply  seated,  however,  they  are  best  treated  locally  by  rather 
severe  massage. 

Diet. — During  the  febrile  stage  of  the  illness  the  diet 
must  be  fluid,  and  should  consist  of  one  or  two  pints  of  milk, 
a  pint  of  barley  water,  and  some  chicken  broth.  Chicken 
broth  and  other  soups  have  been  condemned  in  rheumatic 
fever,  especially  at  a  time  when  the  disease  was  supposed  to 
be  due  primarily  to  an  acid  state  of  the  blood,  on  account 
of  the  fact  that  they  are  rich  in  purin  bodies,  but  there  is 
very  little  evidence  to  show  that,  in  any  disease  in  which 
urates  and  uric  acid  are  precipitated  in  the  urine,  the  intro- 
duction of  a  certain  quantity  of  food  containing  abundance 
of  purin  bodies  has  any  influence  on  the  appearance  of  urates 
and  uric  acid  in  the  urine,  except  when  the  food  containing 
the  purins  is  of  such  a  kind  as  to  give  rise  to  a  large  amount 
of  putrefaction  in  the  intestines.  The  advantage  of  giving 
some  chicken  broth  or  some  other  well  diluted  clear  soup 
during  an  attack  of  fever  is  that  it  seems  to  stimulate  secre- 
tion in  the  stomach,  to  take  the  place,  in  other  words,  of  that 


Rheumatic  Fever.  377 

psychic  stimulus  to  digestion  wliicli  is  present  in  the  liealthy 
person,  but  wliic]i  is  always  absent  in  the  patient  who  is 
suffering  from  fever. 

The  patient  should  be  encouraged  to  drink  freely  either 
of  plain  water,  lemonade,  or  imperial  drink.  Patients  who 
are  subject  to  acute  rheumatism  are  usually  very  thirsty,  and 
no  advantage  is  to  be  gained  by  keeping  them  uncomfortable 
by  limiting  fluids  in  their  dietary. 

After  the  fever  has  subsided,  carbohydrates  may  be 
added  to  the  diet,  and  after  a  week  or  so  fish  and  a  little 
chicken  may  be  introduced,  but  one  has  to  be  cautious  in 
resuming  a  full  diet,  because  for  some  time  the 
patient  may  be  rather  intolerant  of  meat. 

Bacteriology.  — The  bacteriology  of  rheumatic  fever  is 
still  doubtful.  There  seems  every  reason  to  believe  that  it  is 
a  definite  disease,  and  also  that  it  is  caused  by  some  specific 
infective  agent,  but  it  is  not  yet  definitely  established  as  to 
Avhat  this  infective  agent  is,  where  it  comes  from,  or  how  it 
is  introduced  into  the  body.  Various  micro-organisms  have 
been  described  as  having  been  isolated  from  the  joints,  from 
the  blood  both  during  life  and  after  death,  and  from  the 
heart  lesion.  Examinations  of  the  blood  made  during  life 
have  for  the  most  part  been  negative.  In  some  cases  staphy- 
lococci, streptococci  and  diplococci  have  been  found.  On 
examination  of  the  heart's  blood  after  death,  more  positive 
results  have  been  obtained,  and  organisms  have  been  isolated 
besides  the  ordinarj-  pyogenic  cocci,  of  which  the  most  impor- 
tant have  been  the  bacillus  of  Achalme,  the  micrococcns 
rheumaticus  of  Beaton  and  Walker,  and  the  diplococcus 
described  by  Triboulet,  Poynton  and  Paine.  It  is  probable 
that  the  two  latter  are  identical,  and  at  the  present  moment 
both  organisms  are  spoken  of  as  the  diplococcus  rheumaticus. 
Achalme' s  bacillus  is  probably  identical  with  the  bacillus 
enteriditis  sporogenes  of  Klein,  and  it  is  quite  possible  that 
its  presence  in  the  blood  stream  is  the  result  of  an  invasion 
at  the  time  of  death  or  immediately  afterwards. 

None  of  these  organisms  are  found  constantly  in  cases  of 
rheumatic  fever,  and,  although  when  injected  into  animals 
they  produce  a  multiple  arthritis,  there  are  many  organisms 


37S  Chapter  XXII. 

derived  from  sources  other  than  rheumatic  fever  which,  when 
injected  into  animals,  will  also  produce  a  multiple  arthritis, 
such  as  various  strains  of  streptococci  and  cocci. 

It  seems,  therefore,  that  the  specific  organism  of  acute 
rheumatisin  has  not  yet  been  discovered,  and  that  the  true 
etiology  of  the  disease  is  still  unknown,  although  the  disease 
is  probably  a  definite  entity. 

Climatology. — Rheumatic  fever  is  met  with  all  over  the 
world,  but  it  is  specially  common  in  temperate  climates.  It 
is  said  by  many  writers  that  the  United  Kingdom,  and 
especially  England,  is  peculiarly  liable  to  the  occurrence  of 
rheumatic  fever,  and  it  is  probable  that  the  disease  is 
encouraged  by  chill  and  humidity  of  climate.  In  London 
the  autumn  seems  to  be  the  season  in  which  most  people  are 
attacked  by  rheumatic  fever,  but  the  seasonal  incidence  of 
the  disease  varies  considerably  in  different  parts  of  the 
country,  and  while  in  many  districts  the  seasonal  variation  is 
fairly  constant,  there  is  considerable  difference  between  one 
place  and  another  as  regards  the  season  of  greatest  prevalence. 


ACUTE       RHEUMATISM       CHARTS        I     &    2. 


Acute  Rheumatism 
Chart  (Ij     Simple  uncomplicated  case. 
Chart  (2)     Severe  case — death  after  hyperpyrexi 


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(   379  ) 


Chaptee  XXIII. 

YELLOW    FEVER. 

Synonyms. — Black  vomit;  typhus  icterodes. 
German :  Gelbfieber.  , 

French :  Fievre  jaune. 


Definition. —  An  acute  specific  infectious  disease  charac- 
terised by  an  initial  stage  of  continued  fever,  lasting  for  two 
or  three  days,  followed  by  a  remission  which  may  lead  to 
convalescence,  or  which  may  result  in  an  adynamic  condition, 
which  is  accompanied  by  "black  vomit,"  albuminuria,  jaun- 
dice, suppression  of  urine,  and  profound  nervous  disturbance. 

Incubation.  —  The  incubation  period  of  yellow  fever  is 
usually  about  four  or  five  days,  but  may  be  as  short  as 
twenty-four  hours  and  as  long  perhaps  as  twelve  or  thirteen 
days.  Incubation  periods  of  longer  duration  have  beea 
noted,  and  it  is  a  matter  of  common  observation  that  a  period 
bf  something  like  a  fortnight  or  longer  elapses  between  the 
appearance  of  a  patient  suffering  from  yellow  fever  in  any 
district  where  the  disease  is  not  endemic,  and  the  occurrence 
of  the  first  secondary  case.  The  reason  for  this  apparently 
longer  period  of  incubation  is  to  be  found  in  the  study 
of  the  behaviour  of  the  virus  in  the  infected  mosquito,  which 
must  be,  in  the  vast  majority  of  cases,  the  carrier  of  the 
infection. 

Rash.  —  Eruptions  of  various  kinds  appear  in  different 
cases  of  yellow  fever,  the  eruptions  being  usually  petechial, 
erythematous  or  papular,  but  none  of  them  can  be  said  to  be 
diagnostic  of  the  disease.  The  eruption  which  is  most 
characteristic  of  yellow  fever  is  an  erythematous  condition, 
with  much   congestion,   of  the   scrotum  or  the  vulva,   which 


380  Chapter  XXUl. 

appears  in  a  certain  number  of  cases,  and  the  occurrence  of 
which  is  said  by  some  to  be  pathognomonic. 

Period  of  Invasion. — The  period  of  invasion  of  yellow  fever 
is  usually  very  short;  in  fact,  the  disease  usually  attacks  a 
patient  without  any  previous  warning.  The  patient  is  seized 
with  chill,  which  sometimes  only  amounts  to  a  slight  feeling 
of  cold,  but  which  in  many  cases  is  accompanied  by  repeated 
rigors  of  moderate  severity,  alternating  with  periods  of  heat 
and  flushing.  This  period  of  invasion,  which  lasts,  as  a  rule, 
from  two  to  twelve  hours,  and  the  severity  of  which  is  usually 
commensurate  with  the  severity  of  the  subsequent  attack,  is 
associated  with  frontal  headache,  pain  in  the  eyes,  and  severe 
pain  in  the  lumbar  region  and  legs.  The  temperature  rises, 
and  the  patient  is  usually  very  pale.  In  some  cases  the 
acute  period  of  invasion  is  preceded  by  a  few  days  of  general 
malaise,  loss  of  appetite,  headache,  giddiness,  and  constipa- 
tion . 

Clinical  Types.— As  the  feeling  of  chill  passes  off,  the 
patient's  face  becomes  red  and  swollen-looking,  the  eyes  are 
injected  and  watery,  the  headache  increases,  the  pain  in  the 
legs  grows  more  severe,  and  is  felt  particularly  in  the  calves, 
knees  and  ankles.  The  patient  is  restless  and  distressed,  but 
the  mind  is  usually  unclouded.  There  may  be  perhaps  a 
little  wandering  at  night,  but  active  delirium  is  uncommon. 
The  temperature  rises  rapidly  with  the  onset  of  the  disease, 
usually  attaining  its  maximum  within  twenty-four  hours  of 
the  first  appearance  of  definite  symptoms  of  invasion,  and 
remains  high  until  somewhere  about  the  third  day.  The 
respiration  is  rapid  and  laboured;  the  pulse  is  rapid,  usually 
somewhere  between  100  and  120,  and,  during  this  period  of 
initial  fever,  full  and  strong.  The  patient  during  this  time 
is  usually  constipated,  but  sometimes  there  is  considerable 
diarrhoea.  Pain  in  the  epigastrium,  accompanied  by  vomiting 
of  a  clear  acid  fluid,  is  fairly  common.  At  times  the  epigas- 
tric discomfort  may  not  amount  to  pain,  but  may  be  rather 
of  the  nature  of  an  oppression.  The  tongue  becomes  coated 
.with  a  white  fur  on  the  dorsum,  but  is  usually  very  red  at  the 
tip  and  edges.  It  is  not  flabby  and  swollen,  as  is  so  often  the 
case  in  malaria,  but  is,  in  most  instances,  small  and  j)ointed. 


Yellotv  Fever.  381 

This  appeurunce  of  tlio  tongue  is  so  frequently  present  as  to 
constitute  an  aid  to  diiignosis,  especially  between  yellow  fever 
and  malaria.  The  urine  is  scanty  and  often  contains  a  slight 
amount  of  albumin  by  the  second  day  of  illness,  and  the  quan- 
tity of  urea  is  greatly  diminished. 

Somewhere  about  the  third  day  the  temperature  and 
pulse  fall ;  headache,  pain  in  the  limbs,  and  epigastric  dis- 
comfort groM^  less  and  may  disappear;  the  flushed  swollen 
appearance  of  the  face  is  changed,  giving  place  to  pallor, 
and  in  some  cases  to  a  sunken  appearance.  At  the  same 
time  the  injection  of  the  eyes  subsides,  and  for  the  first  time 
the  sclerotics  and  skin  generally  begin  to  assume  the 
yellowish  tint  which  is  so  characteristic  of  the  disease.  After 
this  fall  of  temperature,  the  second  stage  of  the  disease  is 
entered  upon,  which  has  been  called  "the  period  of  calm.'^ 
In  mild  cases  the  disease  ends  at  this  stage,  the  temperature 
quietly  subsides  to  normal,  appetite  returns,  the  urine 
increases  in  quantity,  and  albumin  disappears.  In  severe 
cases,  however,  the  attack  does  not  terminate  in  this  way, 
and,  although  the  symptoms  are  less  acute,  the  patient  is  not 
free  from  discomfort  during  the  "  period  of  calm."  After  a 
period  which  varies  from  a  few  hours  to  a  day  or  two  the 
gastric  symptoms  become  aggravated,  and  the  patient  is 
troubled  by  frequent  vomiting,  either  of  a  clear  fluid  mixed 
with  small  black  particles,  or  a  black  fluid  which  deposits  a 
coffee-ground  sediment  on  standing.  At  the  same  time,  the 
fever  may  rise  higher  while  the  pulse  grows  ^verj  weak  and 
the  patient  suffers  from  uneasiness  in  the  prsecordial  region. 
The  face  is  sunken  and  expressive  of  collapse ;  the  skin  becomes 
more  yellow,  and  the  tint  may,  indeed,  deepen  to  a  dark 
brown.  Haemorrhages  occur  from  the  gums;  the  tongue  is 
dry  and  brown;  petechiae  appear  in  the  skin,  and  sometimes 
gangrenous  areas  form  on  the  limbs  and  on  the  scrotum.  The 
mind  may  remain  unclouded,  but  more  commonly  the  patient 
is  dull  and  listless,  and  even  sinks,  now  and  again,  into  a 
semi-comatose  state.  Delirium  of  an  active  kind  is  some- 
times present.  Hiccough  is  common,  and  subsultus  tendinum 
is  often  seen.  The  patient  is  troubled  with  frequent  cold 
sweats,  and  may  die  either  quietly  from  sheer  asthenia,  usually 


382  Cha'pter  XXIIL 

ill  a  comatose  conditioii,  or  may  suffer  from  violent  convul- 
sions just  before  death.  Vomiting  of  black  material  may 
appear  late  in  the  stage  of  initial  fever,  becoming  less  during 
the  period  of  calm,  only  to  reappear  with  increased  violence 
during  the  secondary  period  of  fever  or  "  period  of  reaction." 
The  early  appearance  of  black  vomit  is  a  very  ominous  sign. 

While  the  majority  of  patients  who  pass  through  the 
period  of  calm  into  the  period  of  reaction  die,  the  occurrence 
of  a  period  of  reaction  does  not  necessarily  mean  that  the  case 
will  terminate  fatally.  In  a  certain  number  of  cases,  the 
temperature  begins  to  subside  a  day  or  two  after  the  period  of 
reaction  sets  in,  the  gastric  symptoms  lessen,  and  the 
patient  slowly  recovers.  Such  cases,  however,  form  a  com- 
paratively small  minority.  During  the  period  of  reaction 
the  temperature  tends  to  be  somewhat  intermittent  in 
character,  and  is  in  most  cases  quite  definitely  febrile.  As 
death  approaches,  however,  the  temperature  tends  to  be  low, 
and  in  some  cases  the  period  of  reaction  is  characterised  from 
the  beginning  by  a  temperature  which  is  normal  or  sub- 
normal. Such  a  temperature  almost  certainly  indicates  a 
fatal  termination  for  the  case. 

In  very  severe  cases,  in  which  black  vomiting  appears 
early,  the  patient  may  die  two  or  three  days  after  the  onset 
of  the  attack  before  any  period  of  calm  sets  in,  and  in  these 
cases  the  temperature  usually  runs  high  until  the  end,  and 
may,  indeed,  show  a  very  pronounced  ante-mortem  rise. 

There  are  other  extremely  grave  forms  of  the  disease,  in 
which  certain  groups  of  symptoms  obtrude  themselves  which 
are  not  common  in  the  usual  course  of  the  illness.  In  some, 
the  patient  is  suddenly  struck  down  by  severe  giddiness, 
followed  by  coma  and  convulsions;  the  pulse  is  weak  from 
the  beginning,  and  speedily  becomes  fluttering  and  irregular; 
the  skin  is  cold,  the  pupils  are  widely  dilated,  and  the  patient 
usually  dies,  comatose,  after  a  few  days'  illness.  In  others, 
the  disease  takes  on  an  algid  form,  in  which  prostration 
appears  early;  the  features  are  sunken,  and  the  surface  of 
the  body  is  extremely  cold;  the  axillary  temperature  is 
markedly  sub-normal ;  the  pulse  is  small  and  "running,"  and  in 


Yellow  Fever.  383 

many  of  these  cases  petechise  are  very  numerous.  In  such  cases 
there  is  seldom  much  yellowness  of  the  skin,  and  any  yellow 
colouration  which  may  appear  is  usually  limited  to  the  coji- 
junctiva.  A  third  type  of  pernicious  case  is  that  in  whicli 
the  symptoms  are  choleraic  in  character,  and  the  patient 
suffers  from  early  collapse,  violent  vomiting  and  extreme 
purging-.  The  skin  is  clammy  and  moist,  and  petechise  are 
numerous.  Death  usually  occurs  in  such  cases  in  the  course 
of  a  few  days,  the  patient  being  profoundly  collapsed. 

The  pulse  in  a  typical  case  of  yellow  fever  is  rapid,  full 
and  bounding  during  the  stage  of  the  initial  fever,  but 
becomes  slow  and  soft  during  the  period  of  calm  and  the 
stage  of  reaction.  Even  in  those  cases  where,  during  the 
period  of  calm,  the  temperature  falls  to  normal  and  convales- 
cence is  thereafter  quickly  established,  the  pulse  may  fall  as 
low  as  50,  and  be  very  soft.  In  those  cases  where  a  period 
of  reaction  sets  in  after  the  period  of  calm,  the  pulse  remains 
slow  and  weak,  and  may  fall  as  low  as  40'.  As  death 
approaches,  the  pulse  is  irregular,  and  sometimes  almost 
imperceptible. 

During  the  period  of  initial  fever  the  blood  pressure 
remains  fairly  normal,  but  it  tends  to  fall  markedly  during 
the  periods  of  calm  and  reaction. 

Complications. —  The  secondary  fever  of  the  period  of 
reaction  may  be  prolonged  for  many  days  or  even  weeks,  on 
account  of  the  occurrence  of  certain  complications,  of  which 
the  most  common  are  abscesses,  boils,  bubonic  swellings  of 
the  lymphatic  glands,  parotitis  and  hepatitis.  These  com- 
^plications  occur  with  very  variable  frequency,  and  are 'more 
common  in  some  epidemics  than  in  others.  They  are  all  of 
unpleasant  significance. 

Diagnosis. — A  well-marked  case  of  yellow  fever,  charac- 
terised as  it  is  by  a  single  febrile  paroxysm,  congestion  of  the 
face,  injection  of  the  eyes,  severe  pain  in  the  back,  albuminous 
urine,  vomiting,  first  of  clear  fiuid  and  afterwards  of  black 
material,  A'ellowish  tinting  of  the  skin  and  sclerotics,  and  the 
occurrence  of  petechise,  is  not  likely  to  be  mistaken  for  any- 
tliins-  else. 


384  Chapter  XXIIl. 

In  the  early  stages  of  the  disease,  lioweA^er,  before  the 
development  of  the  really  characteristic  s^aiiptoms,  there  is 
nothing  in  the  nature  of  the  onset  to  make  a  diagnosis  certain, 
and  in  the  milder  forms  of  the  disease  the  characteristic 
symptoms  may  never  develop  completely,  and  the  attack  may 
consist  entirely  of  a  few  days'  fever,  accompanied  by  pain 
in  the  back,  A^omiting,  and  a  certain  amount  oi  flushing  of 
the  face.  In  such  mild  cases  the  fever  terminates  almost  by 
crisis  at  the  end  of  a  day  or  two,  and  the  patient  may  never 
show  any  icteric  tinting  of  the  skin,  black  vomit,  or  petechise. 

The  locality  in  which  a  suspicious  case  occurs  must  influ- 
ence the  opinion  of  the  physician.  A  case  which  would  give 
rise  to  no  suspicion  in  northern  latitudes  would  be  rightly 
suspect  in  those  regions  where  yellow  fever  is  known  to 
prevail.  Indeed,  any  acute  attack  of  fever  in  districts  where 
yellow  fever  is  endemic  or  apt  to  be  epidemic  should  be  care- 
fully observed,  especially  taking  into  account  the  fact  that 
yellow  fever  is  peculiarly  apt  to  attack  new-comers  to  the 
districts  in  which  it  is  prevalent. 

The  diseases  which  are  most  likel}^  to  be  confused  with 
yellow  fever  are  the  hiiious  remittent  type  of  malaria ,  hJacl- 
water  fever,  and  relapsing  fever. 

The  hiiious  remittent  type  of  malaria  is,  like  yellow  fever, 
common  in  new-comers  to  a  malarious  district,  but  the 
vomiting  in  this  type  of  malaria  is  much  more  definitely 
bilious  in  character  than  in  yellow  fever,  while  albumin  in 
the  urine  is  very  rarely  seen.  In  bilious  remittent  malaria, 
too,  tenderness  in  the  splenic  region  is  present  from  the 
beginning,  and  enlargement  of  the  spleen  is  apparent  as  a 
rule  a  few  days  after  the  onset  of  the  illness.  The  discovery 
of  the  malarial  parasite  in  the  blood,  and  the  presence  of 
pigmented  leukocytes,  make  the  diagnosis  sure. 

In  hlacJcwater  fever,  although  A'omiting  is  quite  common, 
the  enormous  quantity  of  haemoglobin  in  the  urine  and  a 
relative  increase  of  large  mononuclear  leukocytes  containing 
pigment  serve  to  distinguish  this  disease  from  yellow  fever, 
and  it  is  to  be  remembered  also  that  blackwater  fever  never 
attacks  new-comers  to  a  malarious  district,  but  is  a  disease 


Yellow  Fever.  :iS5 

which,  is  found  only  uinoug"  those  wJio  have  spent  a  consider- 
able time  in  tropical  or  sub-tropical  regions. 

RelapaliKj  fever  is  often  accompanied  })y  jaundice,  severe 
pain  in  the  back  and  vomiting,  and  the  vomited  material  may 
be  in  some  cases  black;  but  in  relapsing-  fevej-  alhuiniiniria 
is  not  common,  and  the  spleen  is  most  usually  enlarged. 
Examination  of  the  blood  will  help  to  clear  up  the  differen- 
tial diagnosis.  A  leukocytosis  is  always  present,  with  a  dis- 
tinct relative  increase  of  polymorphs,  while  the  discovery  of 
the  Spirillum  Oberm'eieri  would  place  the  diagnosis  beyond 
question. 

No  specific  organism  has  as  yet  been  discovered  as  the 
cause  of  yellow  fever,  so  that  no  positive  evidence  in  support 
of  diagnosis  can  be  obtained  from  examination  of  the  blood 
of  patients  who  are  suspected  to  be  suffering  from  this  disease. 
There  is  no  doubt,  however,  that  an  organism  of  some  kind 
capable  of  infecting  mosquitoes  exists  in  the  blood  stream, 
but  experiment  has  shown  that  this  organism  must  be 
extremely  small  and  beyond  the  power  of  the  microscope  to 
detect,  since  blood  which  has  been  filtered  through  the  coarser 
bougies  of  a  Chamberland  filter  is  capable  of  infecting  mos- 
quitoes, while  blood  filtered  through  the  finer  bougies  is  not. 

Treatment.  — When  a  patient  has  been  found  to  be  suffering 
from  yellow  fever  he  should  at  once  be  removed  as  far  as 
possible  from  the  infected  area,  and  put  to  bed.  A  hot  mus- 
tard foot-bath  should  be  given,  and  if  he  is  seen  on  the  first 
or  second  day  of  illness,  a  purgative  may  be  administered. 
With  many  physicians,  castor  oil  is  the  favourite  purgative 
at  this  stage,  but  to  b©  of  any  effect  it  must  be  given  in  large 
doses  of  §11.  to  §111.  The  disadvantage  of  castor  oil  is  that 
in  many  people  it  induces  a  considerable  degree  of  nausea, 
and  on  this  account  many  prefer  to  employ  calomel,  giving 
small  repeated  doses  until  5  or  6  grs.  have  been  given, 
following  up  the  calomel  by  a  draught  of  magnesium  sulphate, 
and,  in  the  milder  cases,  giving  some  fluid  magnesia  each  day 
thereafter.  It  is  better,  for  the  most  part,  to  give  a  purga- 
tive only  once,  and  that  in  the  early  days  of  illness,  seeing 
that  gastro-intestinal  irritability  may  be  greatly  increased  by 
the  injudicious  use  of  aperient  drugs. 


386  Chapter  XXIII. 

In  mild  cases  the  foot-bath  and  the  jDiirgative  will  supply 
all  the  treatment  necessary.  In  more  severe  cases  the  mus- 
tard foot-bath  may  be  repeated  more  than  once. 

Various  drugs  have  been  employed  for  the  reduction  of 
temperature,  but  if  they  are  to  be  used  at  all  they  must  be 
used  only  in  the  early  stages  of  the  disease,  seeing  that  the 
great  danger  in  yellow  fever  is  profound  and  increasing  car- 
diac weakness.  Quinine  seems  to  do  no  good,  and  antipyrin 
is  a  dangerous  drug  to  use  in  diseases  where  cardiac  depres- 
sion is  so  profound.  A  simple  saline  mixture,  containing 
acetate  of  ammonium  and  spirit  of  nitrous  ether,  is  perhaps 
the  safest  means  to  employ.  Some  physicians  add  to  this 
mixture  infusion  of  jaborandi  and  tincture  of  aconite,  and, 
in  cases  where  the  skin  is  very  dry,  the  urine  scanty,  and 
lumbar  pain  severe,  this  combination  seems  to  be  of  service. 
For  the  mere  reduction  of  temperature  it  is  better,  in  yellow 
fever  as  in  all  other  acute  fevers,  to  rely  upon  sponging  and 
other  cold  applications  to  the  skin  rather  than  to  any  drugs 
which  have  a  powerful  anti-pyretic  effect. 

Vomiting  may  be  relieved  somewhat  by  the  application 
of  mustard  leaves  to  the  epigastrium,  and  small  quantities 
of  iced  champagne  or  chips  of  ice  are  sometimes  helpful. 

If  there  are  indications  of  collapse  small  doses  of  brandy, 
frequently  repeated,  may  help  the  patient  during  the  emer- 
gency, but  if  there  is  the  slightest  indication  that  alcohol 
increases  the  gastric  irritability  it  must  be  stopped  at  once. 

Sternberg  gives  alkalis  freely  all  through  the  attack, 
giving  the  following  combination: — 150  grs.  of  sodium 
bi-carbonate  and  ^  gr.  of  mercury  perchloride  in  a  quart  of 
water,  of  which  the  patient  takes  §iss.  every  hour.  Manson 
quotes  Sternberg's  results  after  the  use  of  this  form  of  treat- 
ment— 301  whites  were  treated  in  this  way,  and  only  T.3  per 
cent,  died,  while  72  blacks  all  recovered. 

Morphia  is  a  dangerous  drug  to  use  in  yellow  fever. 

For  the  treatment  of  black  vomit  perchloride  of  iron, 
acetate  of  lead  and  the  injection  of  ergotin  have  been  recom- 
mended, but  the  symptom  seems  to  be  refractory  in  most 
cases  to  all  form  of  treatment.  Where  the  gastric  irritability 
is  extreme  and  the  urine  is  scanty,  fluid  should  be  supplied 


Yellow  Fever.  387 

to  the  patient  in  the  form  of  rectal  injections  of  normal  saline 
solution. 

When  heart  failure  is  marked,  the  hypodermic  injection 
of  ether,  strychnine  and  digitalis  should  be  employed. 

Diet. — During  the  period  of  initial  fever  the  patient 
suffers  from  a  marked  degree  of  anorexia,  and  there  is  no 
reason  why  he  should  during  this  time,  which  means  during 
the  iirst  two  or  three  days,  be  forced  to  take  any  nourishment 
whatever. 

As  the  period  of  calm  sets  in,  and  as  the  temperature 
begins  to  fall,  appetite  returns,  and  the  patient  may  exhibit 
a  great  craving  for  food.  In  spite  of  this  craving,  all  food 
should  be  withheld,  except  small  quantities  of  milk  and  lime 
water,  with  perhaps  a  little  chicken-tea.  As  defervescence 
becomes  complete,  the  quantities  may  be  increased,  and  as 
convalescence  proceeds  a  semi-fluid  diet  may  be 
cautiously  begun.  All  solid  food,  however,  should  be  rigidly 
withheld  until  it  is  quite  apparent  that  convalescence  is 
thoroughly  established,  since  any  indiscretion  of  diet  during 
the  period  of  defervescence  and  the  early  days  of  convales- 
cence is  frequently  followed  by  a  relapse.  Relapses  in 
yellow  fever  are  extremely  dangerous,  and  everything  that 
lies  in  the  physician's  power  should  be  done  to  prevent  their 
occurrence. 

If  vomiting  is  troublesome  during  the  period  of  calm 
and  defervescence,  no  attempt  should  be  made  to  give  any- 
thing more  than  very  small  quantities  of  milk  and  lime 
water,  and  nutrition  can  be  aided  by  the  use  of  nutrient  and 
saline  enemata. 

Epidemiology. — ^Yellow  fever  is  endemic  in  certain 
regions,  and,  as  far  as  its  endemic  habitat  is  concerned,  it 
has  a  very  restricted  geographical  distribution.  The  centre 
from  which  it  spreads  is  the  West  Indies,  and  it  extends 
north  to  Mexico  and  the  southern  States,  west  to  Central 
America,  and  south  to  the  coast  of  Brazil.  Until  quite 
recently  the  disease  was  always  present  in  Havana,  and  in 
the  large  coast  cities  of  Brazil  it  has  been  endemic  since  it 
was   introduced   into   Bahia   from    New   Orleans.        In   'New 


388  Chapter  XXIII. 

Orleans,  Monte  Video,  and  Buenos  Ayres  the  disease  must  be 
said  to  be  endemic,  in  so  far  as  it  arises  in  these  cities  without 
any  known  case  being  introduced  from  outside,  but  of  late 
years  its  behaviour  has  been  rather  epidemic  in  these  places, 
and  several  years  may  pass  without  the  appearance  of  a  case. 
It  is,  however,  always  present  in  some  of  the  islands  of  the 
^Vest  Indies.  Since  the  occupation  of  Cuba  by  the  United 
States,  yellow  fever  has  practically  disappeared  from  HaA'ana, 
and  since  the  administration  by  the  United  States  of  the 
region  traversed  by  the  Panama  Canal  a  similar  result  lias 
followed.  The  disease  is  undoubtedly  endemic  in  certain 
parts  of  West  Africa,  but  it  is  not  known  whether  or  not  this 
region  is  its  original  liome.  Epidemics  have  occurred  in 
various  places  as  the  result  of  infection  carried  from  the 
West  Indies  or  elsewhere,  and  such  epidemics  have  been 
severe  in  Spain  and  Portugal.  On  one  occasion  the  disease 
was  carried  from  Spain  to  Italy.  Although  the  epidemics  in 
Spain  and  Portugal  have  sometimes  reached  large  dimensions, 
the  disease  has  never  taken  a  permanent  hold  in  any  European 
country.  Cases  have  been  known  to  occur  in  certain  seaport 
iowns  in  England  and  France,  but  only  in  small  groiips,  and 
as  the  result  of  known  infection  introduced  by  some  ship  on 
Avhicli  the  disease  had  broken  out. 

The  climate  which  favours  the  occurrence  of  yellow  fever 
is  one  where  the  temperature  does  not  fall  lower  than  about 
70°  F.,  and  which  is  damp,  and  the  disease  tends,  there- 
fore, to  spread  in  tropical  and  sub-tropical  climates  during 
the  rainy  season.  An  epidemic  always  ceases  as  freezing 
point  is  approached. 

The  disease  is  confined  mainly  to  seacoast  towns,  and 
towns  which  are  situated  on  the  banks  of  rivers  and  in. flat, 
swampy  country.  It  does  not  as  a  rule  travel  far  inland, 
and  is  uncommon  at  high  altitudes.  It  has,  however,  broken 
out  in  towns  like  Sao  Paulo  in  Brazil  and  Newcastle  in 
Jamaica,  where  the  elevation  is  somewhere  about  2,500  ft., 
and  it  has  also  broken  out  in  Cuzco  in  Peru,  where  the  eleva- 
tion is  over  9,000  ft. 

The  disease  is  not  rapidly  spread  in  rural  communities; 
it  is  essentially  a  disease  of  large  towns. 


Yelloiv  Fever,  389 

At  one  time  ships  were  very  prone  to  be  attacked  in  the 
West  Indies  and  the  low-lying  insanitary  districts  in  the 
neiiflibourliood  of  wharves  and  docks  in  towns  like  New 
Orleans. 

It  is  a  matter  of  common  observation  that  if  a  patient  is 
removed  from  an  endemic  area,  and  means  are  taken  to  isolate 
him  i^roperly,  not  only  from  his  fellows  but  from  mosquitoes, 
he  will  not  sjaread  the  disease,  and  it  is  therefore  quite  safe 
to  visit  a  yellow  fever  patient  under  these  circumstances. 
The  disease,  however,  can  be  acquired  in  places  where  it  is 
endemic  without  coming  into  direct  contact  with  any  patient. 

Prolonged  residence  in  a  place  where  yellow  fever  is 
common  seems  to  bestow  a  certain  amount  of  immunity  on 
many  people,  even  though  they  may  never  have  had  a 
definite  attack  of  the  disease.  It  is  probable  that  such 
people  become  immunised  by  small  and  repeated  doses  of  the 
virus  without  developing  a  true  attack  of  yellow  fever. 

Method  of  Infection.  — There  is  no  doubt  nowadays  that 
yellow  fever  is  due  to  the  action  of  some  parasitic  germ  which 
acts  powerfully  on  the  red  blood  corpuscles,  and  this  germ 
is  present  in  some  form  or  another  in  the  blood  stream  during 
the  first  three  days  of  an  attack  of  yellow  fever.  The  germ 
is  apparently  so  small  as  to  be  invisible  through  the  micro- 
scope, and  will  pass  through  a  Berkefeld  laboratory  filter  and 
also  through  the  Chamberland  porcelain  filter  F.,  although 
it  seems  to  be  arrested  by  the  Chamberland  filter  B.  This 
is  proved  by  the  fact  theit  inoculation  with  the  blood  of  a 
patient  suffering  from  yellow  fever  during  the  first  three 
days  of  illness,  whether  the  blood  be  fresh,  defribinated  or 
filtered  through  a  Berkefeld  filter  or  a  Chamberland  porce- 
lain r.,  will  produce  yellow  fever  in  a  susceptible  person. 
The  disease  is  transmissible  apparently  only  through  the 
agency  of  a  certain  type  of  mosquito,  namely,  the  Stegomyia 
fasciata,  and  then  only  after  a  certain  time  has  elapsed  after 
the  infection  of  the  mosquito  by  virulent  blood.  It  seems 
that  an  incubation  period  in  the  mosquito  of  from  twelve 
to  fourteen  days  is  necessary  before  the  mosquito  is  capable 
of  trahsmittihg  the  disease  to  man.       Endeavours  to  infect 


l)D 


3S0  ChajJter  XXIII. 

susceptible  liumau  beings  with  mosquitoes  from  two  to  ten 
days  after  being  fed  have  been  hitherto  unsuccessful.  An 
infected  mosquito  has  been  known  to  communicate  yellow 
fever  at  fifty-seven  days  after  infection,  and  it  seems  likely 
that  the  infection  becomes  more  virulent  after  a  mosquito 
has  been  kept  for  a  considerable  time  after  infection,  especially 
if  it  is  kept  at  a  temperature  of  about  27°  or  28°  C. 

Marchoux  and  Simond  have  made  a  series  of  experiments 
of  extreme  interest  wdiich  go  to  show  that  the  virus  in  yellow 
fever  can  be  transmitted  b}'  the  infected  parent  to  a  new 
generation  of  insects.  The  eggs  of  a  Stegomyia,  aged  twenty 
days,  which  had  been  fed  on  several  yellow  fever  patients, 
were  hatched,  and  after  they  reached  maturity  the  new 
generation  of  mosquitoes  were  fed  on  glucose  for  a  fortnight. 
One  of  these  young  Stegomyia  was  made  to  bite  a  susceptible 
person  who  had  recently  arrived  in  Brazil,  and  who  was 
guarded  against  all  possibility  of  otherwise  acquiring  the 
infection.  No  yellow  fever  followed.  A  week  later  that 
same  person  was  bitten  again  by  the  same  mosquito,  with 
the  result  that  he  was  seized  with  a  typical,  although  mild, 
attack  of  yellow  fever,  with  characteristic  vomiting,  pains, 
fever  and  icterus.  After  he  recovered  from  this  attack  he 
was  repeatedly  bitten  by  infected  mosquitoes,  but  remained 
quite  immune.  An  interesting  point  which  emerges  from 
this  experiment  is  that  a  mosquito  w4iich  has  just  become 
infected  cannot  transmit  the  disease  until  it  has  been  fed  on 
blood. 

Some  observers  have  noticed  another  interesting  point 
with  regard  to  the  Stegomyia  fasciata ;  namely,  that  before 
the  female  Stegomyia  can  lay  eggs  she  must  first  have  a  feed 
of  blood,  and  the  eggs  are  deposited  about  three  days  after 
she  has  so  fed.  Before  the  first  egg-laying,  the  Stegomyia 
fasciata  feeds  both  during  the  day  and  during  the  night, 
biting  at  any  time.  After  the  first  egg-laying,  however,  she 
bites  only  at  night.  Therefore,  a  Stegomjda  that  bites  during 
the  day  does  not  convey  yellow  fever,  since  she  is  too  young, 
and  any  parasite  she  may  harbour  is  not  mature.  Thus  a 
yellow  fever  centre  may  be  visited  with  impunity  during  the 


Yellow  Fever.  391 

day  even  thoug-h  the  person  may  be  bitten  by  mosquitoes, 
but  becomes  dangerous  at  night,  so  that  Europeans  who  live 
in  the  suburbs  of  certain  towns  in  which  yellow  fever  is 
endemic  may  go  to  business  in  the  low-lying  insanitary  dis- 
tricts of  the  city  and  will  not  contract  the  disease  unless  they 
actually  spend  certain  hours  of  the  late  evening  or  night  in 
tlie  infected  areas. 

The  knowledge  which  observers  in  the  United  States 
Medical  Service  gained  as  to  the  methods  of  infection  in 
3^ellow  fever  and  the  habits  of  the  Stegomyia  were  applied 
in  the  most  practical  way,  both  in  Cuba  and  in  Panama, 
with  the  result  that  the  incidence  of  the  disease  in  these 
regions  has  been  lessened  almost  beyond  belief  since  their 
administration  by  the  United  States. 

Period  of  Infectivity. — It  seems  probable  that  a  patient 
suffering  from  yellow  fever  is  not  capable  of  infecting 
mosquitoes  after  the  first  three  or  four  days  of  illness,  and 
therefore  after  that  period  he  ceases  to  be  a  danger  to  the 
community. 

Death  Rate. — The  death  rate  of  yellow  fever  is  a  very 
variable  quantity.  In  places  where  the  disease  is  endemic, 
or  where  it  appears  at  frequent  intervals  in  epidemic  form, 
the  majority  of  the  adult  population  are  comparatively  insus- 
ceptible, as  the  disease  appears  for  the  most  part  among  new- 
comers and  in  children.  In  children  the  manifestations  of 
the  disease  are  usually  rather  mild,  and  thus  the  mortality 
rate  of  yellow  fever  in  such  districts  may  be  quite  low.  On 
an  average,  the  death  rate  may  be  said  to  vary  from  12  per 
cent,  to  80  per  cent.,  but  may  be  even  lower  in  districts 
where  the  disease  is  endemic,  and  where  new-comers  are  few. 
In  an  epidemic  which  occurred  in  Rio  de  Janeiro  in  1898,  the 
death  rate  reached  the  extraordinary  height  of  94  per  cent. 
A  death  rate  of  between  25  per  cent,  and  30  per  cent,  is  quite 
usual  among  unacclimatised  people.  It  is  to  be  noted  that 
epidemics  of  yellow  fever  in  high  latitudes  where  the  disease 
has  never  become  endemic,  such  as  in  Spain  and  other 
European  countries,  are  usually  attended  by  a  high  death 
rate,  the  mortality  rising  to  something  over  50  per  cent. 

DD    2 


392  Chapter  XXIII. 

The  height  of  the  fever  in  the  acute  period  of  the  attack 
gives  a  good  indication  for  j^rognosis.  According  to  Stern- 
berg, if  the  temperature  does  not  rise  over  103°  F.  the  prog- 
nosis is  good,  whereas  if  the  temperature  is  over  105°  F.  the 
prognosis  is  almost  hopeless,  and  if  the  maximum  tempera- 
ture reaches  between  104°  and  105°  F.  the  odds  on  recovery  are 
about  level.  There  is  no  doubt  that  insanitary  living  and 
dissipation  make  the  chances  of  recovery  from  yellow  fever 
much  less  favourable.  Different  epidemics  in  the  same 
district  may  vary  very  much  in  severity,  some  showing  a  very 
low  death  rate,  and  others  appearing  to  be  very  virulent. 

Second  Attacks  and  Relapses. — Second  attacks  of  yellow 
fever  are  very  rare.  Relapses  are  extremely  dangerous,  and 
usually  occur  as  the  result  of  injudicious  feeding  or  surface 
chill. 

Prophylaxis. — The  prevention  of  yellow  fever  depends 
largely  on  the  destruction  of  the  Stegomyia  and  on  preventing 
mosquitoes  from  being  infected  by  a  patient. 

A  patient  suffering  from  yellow  fever  should,  if  possible, 
be  removed  to  hospital,  and  there  placed  in  bed  surrounded 
with  mosquito  netting,  and  the  removal  of  the  patient  should 
be  carried  out  as  early  as  possible  in  the  illness,  seeing  that 
it  is  during  the  first  three  or  four  days  of  the  attack  that  he 
can  readily  infect  the  mosquito.  Where  it  is  impossible  to 
remove  him  to  hospital,  his  bed  should  be  surrounded  with 
mosquito  netting,  and  the  room  should  be  fumigated 
thoroughly  with  pyrethrum.  Pyrethrum  stupefies  the  insects, 
which  may  be  collected  and  destroyed  while  in  a  stupefied 
condition.  When  a  patient  has  been  removed  to  hospital  the 
whole  house  and  the  houses  adjoining  should  be  subjected  to  a 
rigorous  disinfection,  and,  seeing  that  it  is  of  more  importance 
to  destroy  insect  life  in  these  houses  than  to  remove  infection 
from  clothing  or  the  furniture  of  the  room,  the  best  -method 
of  disinfection  is  by  sulphur  dioxide.  It  is  enough  for 
thorough  disinfection  to  burn  sulphur  in  a  room  to  the  amount 
of  a  pound  and  a  half  per  1,000  cubic  feet.  Bedding  and 
clothing  soiled  by  the  discharges  of  a  yellow  fever  patient 
should  be  thoroughly  disinfected,  not  so  much  from  the  point 


Yellow  Fever.  393 

of  view  i^h at  the  discharges  can  themselves  carry  the  disease 
to  o,ther  people,  but  because  clothing  and  bedding  may  contain 
infected  mosquitoes. 

-  "Measures  to  be  adopted  against  the  Stegomyia  are  similar 
in  every  respect  to  those  recommended  to  be  taken  in  the 
ca.se  Qf  malarious  districts.  The  Stegomyia  is  a  mosquito 
which  tends  to  breed  near  dwelling  houses,  and  it  is  of  the 
utmost  importance  to  see  that  all  standing  water  in  the  neigh- 
bourhood of  houses  is  removed.  Pavements  of  court-yards 
must  be  repaired,  so  that  water  does  not  collect  there  and  form 
more  or  less  permanent  puddles,  while  broken  bottles,  jars, 
empty  cans  and  barrels  are  dangerous  in  so  far  as  they  collect 
water  and  form  a  good  breeding  place  for  the  mosquito. 
Where  the  water  supply  is  dependent  upon  cisterns  and  tanks 
these  receptacles  should  be  carefully  covered  with  gauze.  The 
district  must  be  drained  properly,  irregularities  in  streets 
must  be  filled  up,  and  pools  of  water  which  are  impossible  of 
drainage  should,  as  recommended  in  the  measures  to  be  taken 
against  malaria,  be  covered  with  a  layer  of  petroleum. 

Ships  visiting  infected  ports  should  be  anchored  as  far 
as  possible  from  the  shore  and  from  infected  vessels.  As 
little  communication  with  the  shore  as  possible  should  be 
made,  and  no  one  should  be  permitted  to  leave  the  ship  for 
shore  after  sundown.  Should  a  case  break  out  on  board  a 
vessel,  he  should  be  immediately  taken  on  shore  and  isolated, 
the  ship  should  be  thoroughly  disinfected,  the  holds  being 
fumigated  with  sulphur  before  the  removal  of  the  hatches, 
and  the  whole  vessel,  indeed,  carefully  disinfected  with  sul- 
phur dioxide.  Water  tanks  must  be  protected  with  gauze  as 
on  shore.  No  one  should  be  allowed  to  leave  the  ship  after 
the  occurrence  of  a  case  of  yellow  fever  on  board  until  some 
thirteen  days  have  elapsed,  and  where  it  is  all  possible  the 
vessel  should  be  steered  at  once  for  cold  latitudes,  where  the 
mosquito  will  not  live. 

While  the  disease  is  quite  definitely  propagated  by  the 
mosquito,  and  personal  prophylaxis  consists  largely  in  avoid- 
ing infected  areas  after  sundown,  there  is  no  doubt  that  over- 
fatigue, undue  exposure  of  sun,   and  dissipation  all  tend  to 


394  Chafter  XXIII. 

render  a  person  more  liable  to  infection,  and  people  wlio  have 
to  live  in  the  neighbourhood  of  infected  areas  should  take  the 
greatest  possible  care  to  avoid  the  sun  in  the  middle  of  the 
day,  and  should  live  as  far  as  possible  quiet  and  regular  lives 
and  avoid  alcohol. 

Quinine  and  arsenic  have  been  employed  as  prophylactic 
drugs  at  various  times  and  in  various  places,  but  such 
medication  seems  to  be  of  little  use. 


Yellow  Fever 
Chaiit  (1)     Mild  case — recovery, 
Cii^vitT  (2)     Severe  coee — recovery. 
CiiAUT  (3)     Very  severe  case — death  during  first  stage. 

—death  occurring  witli  subnormal  temperature 


YELLOW       FEVER        CHARTS       1.2.  3    &   4. 


MM 

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(    395  ) 


Chapter  XXIV. 

WHOOPING-COUGH. 

Synonyms  : — Pertussis ;  cliincough. 

French  :    Coqueluche. 
German:   Keuchhusten. 


Definition. — Au  acute  infectious  disorder  characterised  by 
general  catarrh  of  the  air  passages  and  repeated  paroxysms 
of  convulsive  coughing  with  crowing  inspiration,  the 
paroxysms  of  coughing  being  frequently  followed  by  vomiting. 

Rash. — The  disease  is  not  accompanied  by  a  specific 
rash. 

Incubation  Period. — The  incubation  period  in  whooping- 
cough  is  very  variable,  and  on  account  of  its  insidious  onset 
and  the  very  slight  catarrhal  manifestations  with  which  the 
attack  usually  commences,  it  is  very  difficult  to  be  definite. 
It  would  seem  likel}^,  however,  that  the  incubation  stage  may 
vary  from  a  few  days  to  a  fortnight.  In  most  cases  its 
duration  is  probably  between  five  and  eight  days. 

Clinical  Types.  — The  earliest  indications  of  an  attack  of 
whooping-cough  are  those  of  a  naso-pharyngeal  catarrh. 
Occasionally  sneezing  and  lachrymation  are  present,  with 
much  corj^za,  but  as  a  rule  a  little  running  at  the  nose  and 
a  frequent  short  cough  are  the  main  symptoms  which  usher 
in  the  attack.  In  most  cases  there  is  a  considerable  amount 
of  general  malaise,  and  the  patient  is  rather  dull  and  listless, 
taking  but  little  interest  in  his  ordinary  surroundings.  The 
appetite  is  at  first  AA'ell  maintained,  but  tends  to  fail  as  the 
attack  develops.       At    first    the  cough,  although  frequent,  is 


396  Chapter  XXIV. 

not  at  all  paroxysmal,  and  there  is  nothing  to  indicate  that 
the  child  is  suffering  from  anything  more  than  an  ordinary 
naso-pharyngeal  catarrh.  As  the  days  go  on,  however,  the 
cough  increases  greatly  in  severity,  and  tends  to  occur  in 
paroxysms  at  more  or  less  regular  intervals.  Laryngitis  is 
sometimes  noticed  at  this  period  of  illness,  but  is  not  so 
common  in  whooping-cough  as  in  measles.  During  the  early 
stages  of  the  attack  the  patient's  sleep  is  usually  broken  and 
disturbed,  and  it  is  most  commonly  at  night  that  the 
paroxysmal  character  of  the  cough  first  becomes  apparent. 
As  the  cough  begins  to  occur  regularly  in  paroxysms  a 
tendency  to  vomit  after  a  paroxysm  is  very  often  noticed, 
especially  if  the  paroxysm  has  been  severe.  The  rapidity  with 
which  the  parox3'smal  character  of  the  cough  develops  after 
the  first,  onset  of  catarrhal  symptoms  varies  enormously.  In 
very  severe  cases  the  cough  may  be  definitely  paroxysmal, 
accompanied  by  a  crowing  inspiration  and  vomiting  after  a 
paroxysm,  within  three  or  four  days  of  the  first  indication  of 
illness,  while  in  other  less  severe  cases  the  paroxysmal  nature 
of  the  cough  may  be  little  evident  at  first,  and  no  whoop  may 
appear  for  several  weeks.  As  a  rule,  however,  paroxysmal 
cough  is  well  developed  between  a  week  and  a  fortnight  after 
the  onset  of  illness. 

It  is  quite  usual  to  have  comparatively  early  in  the 
catarrhal  stage  of  the  attack  a  little  catarrh  of  the  larger 
bronchi,  so  that  auscultation  reveals  the  presence  of  some 
coarse  rhonchi  all  over  the  chest,  and  in  some  cases,  usually 
af  a  severe  type,  a  widespread  catarrh  affecting  even  the 
smaller  bronchi  may  be  present  almost  from  the  beginning. 
As  a  rule,  however,  the  signs  of  bronchial  catarrh  are  very 
slight  as  compared  with  the  frequency,  persistence,  and 
violence  of  the  cough,  so  that  the  fact  of  a  child  developing  a 
paroxysmal  cough  with  very  few  signs  of  bronchial  catarrh 
should  in  itself  make  tlie  physician  suspicious  of  whooping- 
cough  . 

The  amount  of  fever  present  in  the  pre-paroxysmal  stage 
of  whooping-cough  is  very  variable.     As  a  rule  the  elevation 


Whooping -Cough.  397 

of  temperature  is  very  aligbt,  usually  below  100°  F.,  but  in 
some  cases  the  temperature  may  be  raised  to  between  100° 
and  102°  F. 

It  is  in  the  paroxysmal  stage  that  the  cough  assumes  the 
characters  which  are  typical  of  the  disease.  The  cough  occurs 
in  definite  paroxysms  of  varying  duration  and  frequency,  with 
periods  of  coinplete  rest  between.  A  typical  paroxysm 
consists  of  a  number  of  short  explosive  coughs  following  one 
another  in  very  rapid  succession,  as  Claude  B.  Ker  suggests, 
like  the  explosions  of  a  motor  bicycle  in  starting.  This  series 
of  rapid  coughs  usually  lasts  from  about  fifteen  to  thirty 
seconds,  and  is  followed  by  a  difficult  inspiration  made 
apparently  through  a  greatly  narrowed  glottis,  and  this  in- 
spiration is  accompanied  by  the  crowing  sound  which  forms 
the  w^ioop  so  characteristic  of  the  disease.  In  many  cases 
the  paroxysm  is  now  ended,  but  in  others,  perhaps  the  greater 
number  of  cases,  the  process  is  repeated,  so  that  the  paroxysm 
niay  consist  of  many  attacks  of  rapid  explosive  coughs  lasting 
some  fifteen  to  thirty  seconds  interrupted  by  a  number  of 
crowing  inspirations  or  whoops.  The  paroxysm  is  not  infre- 
quently terminated  by  an  attack  of  vomiting,  and  in  those 
cases  where  vomiting  does  not  occur  a  large  amount  of  glairy 
mucus  is  expelled  from  the  mouth  at  the  end  of  a  paroxysm. 
This  expulsion  of  mucus  occurs  even  in  very  young  children, 
and  the  fact  that  a  fit  of  coughing  is  followed  by  the 
expectoration  of  mucus  in  a  child  who  is  below  the  age  at 
which  expectoration  is  usually  possible  is  of  itself  very 
suggestive  of  whooping-cough.  While  fifteen  to  thirty  seconds 
is  a  common  period  for  the  rapid  coughing  to  continue  before 
an  inspiration  occurs,  in  very  bad  cases  the  rapid  coughs  may 
continue  for  forty-five  seconds,  or  even  rather  more  than  a 
minute,  before  the  patient  is  relieved  by  a  successful  inspira- 
tion, even  of  a  crowing  and  unsatisfactory  kind.  It  is  true 
that  during  the  occurrence  of  such  an  attack  there  may  be 
momentary  cessation  of  the  coughing  and  an  attempt  to  take 
breath,  but  the  attempt  may  be  more  than  once  unsuccessful 
before  the  coughing  is  interrupted  by  a  crowing  inspiration. 


398  Chavter  XXIV, 

The  distress  of  the  patient  during  such  an  attack  is 
terrible.  The  face  grows  purple,  the  eyes  are  suffused  and 
blood-shot,  and  the  lips  may  be  almost  black ;  glairy  mucus 
comes  froju  the  nostrils  and  the  mouth,  the  tongue  is  pro- 
truded, swollen  and  very  dark  in  colour,  and  bleeding  may 
occur  from  the  pressure  of  the  fraenvm  lingitce  on  the  teeth 
of  the  lower  jaw.  In  rare  cases  syncope  and  death  have 
occurred  in  such  paroxysms,  but  as  a  rule  just  as  the  case 
appears  to  be  i?i  extremis  a  relaxation  of  the  glottis  occurs, 
and  an  inspiration  relieves  the  condition. 

The  number  of  paroxysms  which  occur  in  twenty-four 
hours  may  be  as  high  as  twenty-four  and  as  low  as  one,  but 
ten  or  twelve  paroxysms  is  a  very  usual  number.  It  is  curious 
to  observe  the  extraordinary  variation  of  attacks  of  whooping- 
cough  both  as  regards  frequency  and  duration  of  paroxysms 
in  different  individuals  of  the  same  family  during  the  same 
epidemic.  While  one  child  may  have  during  the  day  two 
or  three  paroxysms  of  short  duration,  followed  by  easy 
vomiting,  and  be  otherwise  in  no  way  disturbed,  another  may 
be  fretted  both  day  and  night  by  the  occurrence  of  a  paroxysm 
almost  every  hour,  a  paroxysm  which  may  be  composed  of 
very  many  attacks  of  frequent  coughing  interrupted  by 
crowing  inspiration  before  it  is  terminated  by  vomiting  or  a 
spluttering  expectoration  of  mucus. 

As  a  rule,  the  child  has  a  definite  warning  of  the  occur- 
rence of  a  paroxysm,  and  becomes  restless,  seizes  the  side  of 
his  bed,  clings  to  anyone  within  reach,  and  possibly  cries. 
As  a  rule  the  crying  is  immediately  followed  by  the  occur- 
rence of  the  paroxysm.  The  warning  appears  to  be  either  a 
tickling  sensation  in  the  throat  or  behind  the  sternum  or  a 
sense  of  constriction  in  the  chest;  in  some  cases  it  appears 
to  be  a  sensation  of  giddiness,  accompanied  by  yawning,  or  it 
may  be  that  the  child  is  seized  with  an  attack  of  sneezing. 
This  warning  occurs  as  a  rule  a  few  minutes  before  a 
paroxysm.  The  taking  of  food  or  drink  will  often  precipitate 
a  paroxysm,  and  this  in  severe  cases  is  a  great  inconvenience, 
seeing  that  when  a  paroxysm  occurs  immediately  after  a  meal 


Whooping -Cough.  399 

much  of  the  food  is  likely  to  be  vomited,  and  it  is  very 
difficult  to  maintain  the  nutrition  of  a  patient  under  these 
conditions. 

During  the  paroxysm  the  pulse  rate  is  greatly  accelerated, 
but  unless  the  attack  be  very  severe  and  the  paroxysms  fre- 
quent and  prolonged  the  pulse  rate  drops  to  normal  between 
the  paroxysms,  and  the  child  is  in  other  respects  quite 
comfortable. 

The  paroxysmal  stage  of  the  disease  lasts  as  a  rule  for 
about  a  month  or  six  weeks,  although  in  certain  cases  it  may 
be  shorter  and  in  others  much  longer.  It  is  usually  at  its 
worst  during  the  second  and  third  weeks,  and  thereafter  the 
attack  gradually  passes  off,  the  paroxysms  becoming  less 
frequent  and  less  severe,  until  they  disappear  altogether. 

The  danger  of  an  attack  of  whooping-cough  depends 
largely  upon  the  age  and  condition  of  the  patient.  An  attaxk 
during  the  first  three  years  of  life  is  apt  to  be  much  rsjore 
dangerous  than  one  occurring  in  an  older  child.  This,  of 
course,  depends  to  a  great  extent  upon  the  fact  that  very 
young  children  are  incapable  of  the  serious  and  prolonged 
effort  necessary  to  weather  a  severe  and  possibly  complicated 
attack  of  whooping-cough,  and  also,  as  in  all  catarrhal  illnesses 
in  children,  the  mortality  tends  to  be  higher  before  the  age 
at  which  nose-blowing  and  expectoration  become  easy  than 
after  it.  Eickety  children  are  badly  handicapped  from  the 
start,  both  on  account  of  the  softness  of  their  chest  wall,  and 
from  the  fact  that  they  are  curiously  prone  to  bronchial 
catarrh  and  broncho-pneumonia. 

Complications. — The  most  important  complications  which 
occur  during  the  course  of  whooping-cough  are  those  con- 
nected with  the  respiratory  system.  It  is  probably  true  that 
a  hronchial  catarrh  is  so  common  that  it  can  scarcely  be 
classed  as  a  complication,  but  whereas  it  is  usually  slight 
and  confined  to  the  larger  bronchi  it  is  sometimes  severe  and 
of  a  capillary  kind.  The  bronchial  catarrh  is  dangerous  in 
proportion  to  the  extent  of  involvement  of  the  small  bronchi. 
Broncho-pneumo?iia  is  a  frequent  and  dangerous  compli- 
cation.      In  the  course  of  a  broncho-pneumonia  the  whoop  is 


400  Chapter  XXIV, 

usually  suppressed^  but  sometimes  a  spasm  of  the  glottis  may 
occur  which  is  a  grave  danger.  Laryngitis  may  occur  in 
whooping-cough  as  in  measles,  in  connection  with  the  broncho- 
pneumonia, but  less  commonly.  Collaijse  of  the  lung  occurs 
usually  in  association  with  broncho-pneumonia.  If  the  col- 
lapse involves  a  large  area,  especially  in  infants,  alarming 
symptoms  may  suddenly  arise,  and  the  child  may  fall  back 
livid,  with  shallow  and  rapid  respirations,  cold  and  clammy 
skin.  Sudden  syncope  and  death  may  occur  immediately,  or 
a  series  of  convulsions  may  result.  In  infants,  broncho- 
pneumonia is  nearly  always  fatal,  particularly  if  there  is  any 
extensive  collapse  of  the  lung,  and  even  in  older  children  it 
is  a  complication  of  considerable  gravity.  Broncho- 
pneumonia usually  attacks  the  lower  part  of  the  lungs,  and 
in  association  with  this  condition  a  certain  amount  of 
coniijensatory  emijliysevxa  is  usual.  In  severe  protracted 
cases  the  emphysema  may  be  extensive  and  persistent  through 
convalescence,  and  the  patient  may  remain  for  life  hampered 
with  this  condition  from  very  early  years.  The  temperature 
in  whooping-cough  after  the  first  week  is  usually  normal 
unless  some  pulmonary  complication  occurs,  and  any 
considerable  rise  in  temperature  should  always  suggest  the 
occurrence  of  broncho-pneumonia. 

Lobar  imeinnonid  is  a  very  rare  complication,  as  is 
•pleurisy  with  effusion,  but  both  are  occasionally  met  with. 
The  usual  time  for  pulmonary  complications  to  occur  is  about 
the  second  or  third  week  of  the  paroxysmal  stage  of  the 
disease. 

Convulsions  are  frequently  met  with  as  a  complication  of 
whooping-cough,  sometimes  alone  but  very  frequently  in 
association  with  a  capillary  bronchitis  or  a  broncho- 
pneumonia. When  they  occur  they  should  always  excite 
alarm  in  the  mind  of  the  physican,  since  while  they  are 
sometimes  infrequent  and  slight  they  are  often  severe,  and 
even,  especially  when  associated  with  a  pulmonary  compli- 
cation, fatal.  The  convulsions  are  probably  in  most  cases 
part  of  the  general  toxic  condition  of  the  patient,  and  in  the 
majority  of  autopsies  conducted  on  cases  who  have  suffered 


Whooping -Cough.  401 

from  couvulsions  in  the,  course  of  wliooping-cougli  no  gross 
lesion  of  the  brain  is  found.  In  a  certain  proportion  of 
cases,  however,  the  convulsions  seem  to  be  due  to  the  rupture 
of  cerebral  arteries  or  thrombosis  of  veins  and  sinuses. 
They  occur  more  frequently  in  rickety  children  and  in 
children  who  are  in  the  process  of  teething  than  in  any  other 
kind  of  case.  In  other  words,  they  occur  most  readily  in 
those  patients  who  are  most  prone  to  suffer  from  the  general 
nervous  irritability  so  characteristic  of  whooping-cough.  In 
some  cases  they  indicate  the  onset  of  a  pulmonary  compli- 
cation, taking  the  place  as  in  other  diseases  of  the  rigor  of 
adults.  Convulsions  usually  occur  in  severe  and  complicated 
cases,  but  they  do  occur  in  cases  otherwise  very  mild,  and 
while  in  this  latter  class  they  are  commonly  slight  and 
transient,  they  may  sometimes  be  troublesome  and  even 
dangerous. 

Various  hcemorrhages  due  to  the  strain  of  coughing  are 
often  seen  in  whooping-cough.  Bleeding  from  the  nose  is 
common,  and  a  slight  bleeding  from  the  pharynx  and  bronchi 
is  also  fairly  frequent.  Sub-con junctival  haemorrhages  are 
common,  and  haemorrhage  into  the  eyelids,  giving  the 
appearance  of  an  ordinary  "  black-eye,"  is  sometimes  met  with. 
Blood  coming  from  the  nose  is  often  swallowed,  and  may  be 
vomited,  or,  passing  downwards  into  the  bowel,  may  produce 
melaena.  Hsemorrhage  from  the  ear  either  with  or  without 
rupture  of  the  tympanum  has  occasionally  been  noted  as  a 
very  rare  complication  of  whooping-cough. 

Disturbances  of  the  digestive  tract  are  also  common. 
Vomiting,  while  usually  the  direct  result  of  the  paroxysms  of 
coughing,  may  occur  quite  independently  of  these  paroxysms, 
and  the  vomited  material  contains  large  quantities  of  thick 
ropy  mucus.  Digestion  is  difficult,  and  distention  of  the 
stomach  is  common.  DiarrJicea,  with  thin,  watery  and  some- 
times mucous  stools,  is  a  very  frequent  complication  of 
whooping-cough,  and  may  be  difficult  to  check.  In  a 
previously  strong  and  healthy  child  digestive  disturbances  do' 
not  usually  give  cause  for  any  anxiety,  but  in  weakly  children 


402  Chapter  XXIV. 

they  are  dangerous  iu  so  far  as  they  render  difficult  the 
adequate  maintenance  of  nutrition.  Ft'ohiijue  of  the  rectum 
and  hernia  may  occur,  being-  due  to  the  frequently  repeated 
strain  of  coughing.  Miniite  quantities  of  albumin  and  sugar 
are  very  frequently  found  in  the  urine,  but  true  ne'phritis 
is  a  complication  of  great  rarity.  Acute  dilatation  of  the 
heart  with  pulmonary  oedema  has  occasionally  been  observed, 
but  is  very  uncommon.  When  it  does  occur  it  is  usually 
fatal. 

SequelaB. — The  most  important  sequela  of  whooping- 
cough  is  tuberculosis  in  its  various  forms.  It  would  seem 
that  the  child  who  has  been  weakened  by  whooping-cough 
falls  a  ready  prey  to  infection  by  the  tubercle  bacillus, 
which  has  either  been  acquired  after  he  begins  to  go  about 
again,  or  has  been  dormant  in  his  tissues  before  the  develop- 
ment of  whooping-cough.  While  pulmonary  tuberculosis  is 
the  most  common  form  which  occurs  in  children  who  have 
had  a  prolonged  broncho-pneumonia,  tubercle  of  the 
lymphatic  glands  and  even  bone  is  also  not  uncommon. 
Rickets  is  frequently  met  with  as  a  sequela  of  whooping- 
cough,  and  in  cases  where  rickets  has  been  present  before  the 
attack  the  deformity  of  the  chest  resulting  from  the  strain  of 
coughing  may  be  very  great.  Ev^jhysema  with  a  tendency 
to  bronchitis  and  asthma  may  persist  through  life  as  the  result 
of  an  attack  of  whooping-cough  in  childhood. 

Children  remain  irritable  for  long  after  the  attack  of 
whooping-cough  has  passed,  and  often  suffer  from  unreason- 
able terrors,  both  during  the  day  and  at  night.  In  many 
children  any  slight  catarrh  which  occurs  after  an  attack  of 
whooping-cough  may  during  the  next  six  months  or  a  year 
be  accoimpanied  by  cough  of  a  paroxysmal  character  and 
frequently  a  well  developed  whoop  which  may  suggest  a 
recrudescence  of  the  disease. 

A  certain  amount  of  dilatation  of  tJie  heart  may  persist 
for  a  long  time  after  the  subsidence  of  a  severe  attack,  and 
although  as  a  rule  this  dilatation  disappears  completely  in  a 
reasonable  time  after  convalescence  is  established,   it  would 


Whooping -Cough.  403 

seem  that  in  some  cases,  at  least,  permaneut  damage  to  llie 
heart  may  result.  Endocarditis  and  'pericarditis  are  prac- 
tically never  seen.  Chronic  otitis  media  is  occasionally 
observed  as  a  sequela,  and  is  frequently  associated  with 
considerable  enlargement  of  the  cervical  lymphatic  glands. 

Diagnosis. —  The  diagnosis  of  whooping-cough  in 
the  early  catarrhal  stage  is  extremely  difficult,  if  not 
impossible.  The  cough  at  first  is  in  no  way  typical,  and 
although  when  an  epidemic  of  whooping-cough  is  known  to  be 
in  the  neighbourhood  any  persistent  catarrh  with  frequent 
cough  should  suggest  the  possibility  of  the  attack  being 
whooping-cough,  it  is  not  until  the  cough  becomes  less 
frequent  and  occurs  in  sudden  attacks  with  intervals  of  rest 
between,  although  it  may  not  be  actually  paroxysmal,  that 
the  case  begins  really  to  suggest  the  possibility  of  whooping- 
cough.  Where  whooping-cough  is  suspected  the  child  should 
be  observed  carefully  during  the  night,  as  it  is  almost  always 
during  the  night  that  the  true  paroxysms  begin  to  develop, 
and  the  first  whoop  occurs. 

The  examination  of  the  blood  may  in  many  cases  help 
one  in  diagnosis.  It  would  appear  that  even  comparatively 
early  in  the  catarrhal  stage  a  leukocytosis  is  very  common, 
and  as  the  cough  approaches  the  paroxysmal  type  a  relative 
increase  in  lymphocytes  over  polymorphs  becomes  apparent, 
sometimes  in  an  extraordinary  degree.  But  as  the  diagnosis 
of  whooping-cough  depends  largely  on  busy  practitioners  it 
cannot  be  expected  that  they  should  employ  this  method  of 
diagnosis,  which  is  cumbersome  and  requires  considerable 
technical  skill. 

In  the  paroxysmal  stage  when  well  developed  the 
diagnosis  is  very  easy.  The  sudden  and  explosive  onset  of 
the  paroxysms  and  the  occurrence  of  the  whoop  are  absolutely 
diagnostic.  Sometimes,  however,  the  paroxysms  are  badly 
developed  and  no  whoop  occurs,  and  in  such  cases  diagnosis 
even  in  the  paroxysmal  stage  may  be  a  matter  of  some 
difficulty.  The  spluttering  occurring  at  the  close  of  these  ill- 
developed  paroxysms  is  very  suggestive,  and  the  fact  that  at 


404  Chapter  XXIV. 

their  termination  fairly  copious  expectoration  of  mucus  occurs 
even  in  very  young  children,  is  often  sufficient  ground  for  a 
provisional  diagnosis  that  may  afterwards  be  verified  by  the 
development  of  a  whoop.  As  mentioned  earlier  in  the  chapter, 
a  persistent  cough  tending  to  be  paroxysmal  accompanied 
by  the  expectoration  of  mucus  with  practically  no  physical 
signs  of  bronchial  catarrh  in  the  chest  should  always  make 
one  suspect  that  the  child  is  suffering  from  whooping-cough. 
The  cough  produced  by  enlarged  tonsils  and  naso-pharyngeal 
catarrh  is  often  very  like  whooping-cough,  but  the  onset  of 
the  paroxysm  is  not  so  explosive,  nor  is  the  cough  followed  by 
the  expectoration  of  mucus  in  very  young  children.  The 
throat  should  always  be  examined  to  exclude  the  possibility 
of  the  cough  being  due  to  enlarged  tonsils,  and  also  because 
examination  of  the  throat  often  excites  a  paroxysm  which 
may  render  diagnosis  certain.  The  discovery  of  a  small  ulcer 
on  the  fraemim  linguae  is  strongly  suggestive  of  whooping- 
cough,  and  puffiness  of  the  eyelids  and  congestion  of  the  eyes 
and  face  may  also  be  taken  as  confirmatory  evidence,  but  it 
is  uncommon  to  have  these  conditions  present  in  cases  where 
the  diagnosis  is  reasonably  doubtful. 

The  catarrhal  stage  in  whooping-cough  associated  with 
much  coryza  may  suggest  the  onset  of  measles,  but  if  no  rash 
appears  within  a  week  and  no  Koplik's  spots  are  evident, 
measles  must  be  excluded.  Foreign  bodies  in  the  larynx  may 
produce  ^^ai'oxysms  very  like  those  of  whooping-cough,  and 
enlargement  of  the  bronchial  glands  has  been  known  to  pro- 
duce a  cough  which  resembles  very  closely  the  whooping-cough 
paroxysm.  In  these  conditions,  however,  the  expectoration 
of  mucus  does  not  usually  terminate  the  attack  of  cough. 

Treatment. — In  the  treatment  of  whooping-cough  the 
general  care  of  the  patient  is  of  infinitely  greater  importance 
than  any  particular  form  of  drug  treatment.  In  treating  a 
patient  in  a  private  house  where  there  is  sufficient  accommo- 
dation for  the  proper  management  of  the  case,  there  is  little 
doubt  that  the  Ijest  and  safest  method  of  treatment  is  to  con- 
fine the  patient  entirely  to  two  rooms,  one  used  during  the 


Whooping -Cough  405 

day,  the  other  during  the  night,  both  kept  at  an  even  tem- 
perature, and  ventilated  properly  without  draught.  Many 
people  lay  great  stress  upon  the  open-air  treatment  of 
whooping-cough,  and  it  is  possible  that  in  cases  who  would 
otherwise  be  the  inmates  of  crowded  hospital  wards,  balcony 
and  garden  treatment  is  better  than  the  alternative  condition. 
It  is,  however,  a  dangerous  doctrine  to  urge  upon  the  general 
public,  especially  as  at  the  present  moment  people  are  suffi- 
ciently heedless  of  the  exposure  to  which  they  subject  their 
children  who  suffer  from  whooping-cough  in  the  early  stages 
to  need  little  encouragement  in  this  direction.  That  the 
death-rate  of  whooping-cough  is  so  high  cannot  be  a  matter 
of  surprise  when  one  sees  the  foolhardy  way  in  which  children 
who  are  evidently  to  the  most  superficial  observer  in  the  early 
stages  of  whooping-cough  are  permitted  to  go  out  and  be 
taken  out  in  the  inclement  east-windy  weather  of  the  English 
spring.  It  is  surely  unreasonable  to  expose  a  child  to 
inclement  weather  and  the  risk  of  surface  chill  when  the 
complaint  from  which  he  suffers  is  characterised  largely  by 
catarrhal  symptoms,  and  the  most  fatal  of  whose  complications 
are  acute  bronchitis  and  broncho-pneumonia.  In  whooping- 
cough  as  in  every  other  disease  the  prevention  of  complications 
is  of  greater  importance  than  their  cure,  and  granted  sufficient 
air  for  the  child  in  well  ventilated,  evenly  heated  apartments, 
there  should  be,  with  proper  recognition  of  early  cases  and 
reasonable  care  in  the  conduct  of  the  case,  a  great  reduction 
in  the  mortality  of  whooping-cough  from  these  means  alone. 

The  fact  that  whooping-cough  is  not  notifiable  is  one  of 
the  great  difficulties  in  its  treatment.  In  the  poorer  classes 
of  the  community  the  gravit}^  of  infectious  diseases  is  as  a 
rule  estimated  only  by  the  fact  that  the  patients  are  either 
removable  to  hospital  or  are  not,  and  measles  and  whooping- 
cough,  whose  death-rate  is  enormous  as  compared  with  the 
death-rate  from  scarlet  fever,  are  looked  upon  by  the  poorer 
classes  as  trivial  ailments  unless  a  severe  complication,  such 
as  broncho-pneumonia,  should  arise.  It  is  to  the  careless 
handling  of  the  case  in  its  early  stage    that    the  enormous 

EE 


406     •  Chapter  XXIV. 

deatli-rate  in  wliooping-cougli  is  largely  due.     AVliere  possible, 
therefore,  one  cannot  urge  too  strongly  on   any  practitioner 
tlie  importance  of  the  early  diagnosis  of  whooping-cough,  and 
stringent  treatment  on  suspicion.     Hospital   experience   goes 
to  show  that  in  cases  who  are  brought  early  to  hospital  during 
an  epidemic  of  some  size,  the  mortality  rate  is  infinitely  lower 
even   in  weakly  and  badly   developed   children  than  that  in 
cases   which   have  been   allowed   to   drift   into   the   second   or 
third  week   of  the  paroxysmal  stage    before    being    sent    to 
hospital.     In   private  practice   among  patients   of  the   better 
class  this   difference   is   even  more  extraordinary,    and    it    is 
difficult   to   understand  how  after  many  years  of   experience 
certain  practitioners  persist  in  regarding  whooping-cough  in 
the  early  stage  a  trivial  malady,   and  only  institute  careful 
treatment    of    the   patient   on    the   occurrence   of    bronchial 
catarrh  or  broncho-pneumonia.        Since,  however,   the  larger 
number  of    cases   of    w^iooping-cough    which    occur    in    this 
country  appear  in  the  homes  of  people  who  are  unable  perhaps 
to  set  apart  even  one  room  entirely  for  the  treatment  of  the 
patient,  one  must  devote  some  attention  to  the  management 
of  such  cases  in  hospital.     The  open-air  treatment,  like  the 
open-air  treatment  of   phthisis,    is   in   this   country  open    to 
certain   grievous   inconveniences,    and     even     dangers.        One 
cannot  believe  that  direct  exposure  to  the  bitter,  inclement, 
and  contaminated  atmosphere  of  a  city  can  be  in  any  way 
beneficial  to  patients  suffering  from  whooping-cough.       It  is 
better,  therefore,  in  the  management  of  such  cases  in  hospital 
to  treat  them  in  large  airy  wards  which  are  maintained  at  a 
regular   temperature   and    well   ventilated    without   draught, 
than  to   expose  them  on  balconies  or  in  the  gardens  of  the 
hospital.     If  whooping-cough  wards  are  allowed  to  be  in  any 
way  over-crowded  complications  arise  in  a  proportion  of  cases 
that  is  quite  unjustifiable.     If,  however,  the  whooping-cough 
child  is  allotted  an  amount  of  space  in    the    wards    greater 
than    that    in    any    other    infectious    disease,    save    perhaps 
measles,  and  proper  precautions  are  taken  by  the  attendants 
to  see  that  the  mucus  which  is  spluttered  about  at  the  end  of 
a  paroxysm  is  collected  in  a  suitable  spittoon,  and  the  child's 


Whooping-Co'ugh.  407 

mouth  and  face  generally  are  carefully  cleauwed  after  each 
j)aroxysm,  the  chance  of  a  ward  becoming  dangerously 
infected  is  enormously  lessened.  The  spittoon  should  be  placed 
within  the  easy  reach  of  every  child  old  enough  or  strong 
enough  to  use  it,  and  the  child  must  be  trained  to  seize  it  at 
the  commencement  of  every  paroxysm,  and  spit  into  it  at  its 
close,  while  it  ought  to  be  the  care  of  the  nurse  on  duty  in 
the  ward  to  attend  all  weakly  and  very  young  children 
during  a  paroxysm,  and  encourage  expectoration  into  the 
sj)ittoon  as  the  paroxysm  terminates,  cleaning  the  mouth  and 
face  after  the  mucus  has  ceased  to  be  expectorated.  Such  pre- 
cautions undoubtedly  lessen  the  risk  of  grave  complications 
arising  in  a  whooping-cough  ward,  and  in  eight  months  out 
of  our  year,  in  any  case,  such  measures  are  safer  than  any 
attempt  at  habitual  open-air  treatment. 

If  these  remarks  are  true  with  regard  to  ordinary  cases 
of  whooping-cough  without  complications,  they  are  doubly 
true  of  cases  which  are  complicated  by  broncho-pneumonia 
during,  at  any  rate,  the  acute  stage.  If,  however,  the 
broncho-pneumonia  tends  to  be  chronic  and  hang  long  in  the 
wind  during  convalescence,  it  is  certainly  an  excellent  plan 
to  have  the  child's  bed  taken  into  the  open-air  for  the  greater 
part  of  the  day,  when  such  weather  as  we  can  boast  of 
permits.  Damp,  raw  w^eather  and  the  dry,  cold  east  wind 
which  stirs  up  the  dust  so  easily  are  never  conditions  of  climate 
to  which  one  would  wish  even  a  chronic  broncho-pneumonia 
exposed. 

With  regard  to  drug  treatment  it  is  impossible  to  devote 
space  to  discussion  of  all  the  medicaments  which  have  been 
recommended.  The  medication  of  the  atmosphere  of  the  sick 
room  by  the  volatilisation  of  creosote  or  eucalyptus  has  many 
advocates,  and  it  is  possible  that  the  vapour  of  creosote  may 
in  some  cases  lessen  the  severity  of  the  spasm.  On  the  other 
hand,  the  medication  of  an  atmosphere  involves,  to  make  it 
of  any  avail,  a  certain  amount  of  deficiency  in  ordinary  venti- 
lation, and  it  would  seem  unlikely  that  the  exclusion  of  pure 

EK   2 


408  Chapter  XXIV. 

air  would  be  in  any  way  compensated  for  by  the  continuous 
inhalation  of  a  drug. 

Butyl-choral-liydrate,  belladonna,  the  bromides,  pare- 
goric and  other  forms  of  opium,  and  many  other  drugs  have 
been  so  strongly  advocated  that  it  would  be  almost  heresy  to 
say  that  in  most  cases  they  could  all  be  dispensed  with.  Yet 
it  is  perfectly  true.  The  average  uncomplicated  case  of 
whooping-cough  requires  no  drug  treatment  whatever,  except 
when  the  paroxysms  are  very  frequent  and  very  severe.  Of 
all  the  anti-spasmodics  the  tincture  of  belladonna  and  alcohol, 
preferably  in  the  form  of  whisky,  will  probably  be  found  to 
be  of  the  greatest  service  in  the  treatment  of  such  cases.  It 
is  necessary  to  push  belladonna  until  its  effects  are  very 
noticeable,  until,  indeed,  the  pupils  are  definitely  dilated.  It 
maj'-  be  given  even  to  young  children  in  doses  of  from  two  or 
three  minims  every  four  hours,  and  this  dose  may  be  quietly 
increased  every  day  by  the  addition  of  a  minim  to  each  dose 
until  as  large  a  dose  as  ten  to  fifteen  minims  thrice  daily  may 
be  given.  The  condition  of  the  pupil  or  the  occurrence  of  a 
rash  and  signs  of  belladonna  excitement  show  one  that  the 
limits  of  toleration  have  been  reached.  In  very  susceptible 
persons  it  may  be  found  that  a  dose  of  even  two  or  three  minims, 
of  the  tincture  every  four  hours  may  be  too  much  for  their 
powers  of  toleration,  in  which  case  belladonna  must  be  looked 
upon  as  a  drug  unsuited  for  their  condition.  Belladonna 
combined  with  small  doses  of  sodium  bromide,  2  or  3  grs. 
every  three  or  four  hours,  will  often  be  of  service  in 
diminishing  the  severity  of  the  paroxysms,  although  it  is  very 
doubtful  as  to  whether  any  drug  treatment  will  reduce  their 
frequency. 

It  is  of  the  greatest  importance  that  children  who  suffer 
from  whooping-cough  should  have  as  much  sleep  as  possible, 
at  least  during  the  night,  that  the  intervals  between  their 
paroxysms  should  be  as  quiet  and  free  from  nervous  excite- 
ment as  possible.  For  this  purpose  the  habit  of  giving 
30  minims  or  a  drachm  of  whisky  with  a  little  hot  water  and 
sugar  towards  the  evening  and  continued,  at  least  through 
the  early  part  of  the  night,  at  intervals  of  two  or  three  hours 


J 


Whooping -Cough.  409 

is  justified  by  experience,  and  where  hypnotics  are  in  any  way 
necessary  there  is  none  so  safe  as  whisky.  Paregoric  and 
Dover's  powder  are  frequently  of  great  service  if  used  in  a 
similar  way,  that  is  to  say,  in  small  doses  and  towards  the 
end  of  the  day,  but  many  will  agree  that,  where  the  danger 
of  acute  bronchitis  and  broncho-pneumonia  is  so  great,  the 
less  opium  that  is  used  the  better,  especially  in  the  case  of 
very  young  children. 

Where  convulsions  occur,  the  best  drug  to  use  is  chloral 
hydrate,  which  should  be  given  in  an  aqueous  solution  per 
rectum,  either  during  or  just  after  the  occurrence  of  the  first 
convulsion.  It  may  be  repeated  twice  daily  as  a  preventive 
after  the  passing  of  the  first  convulsion,  or  given  during  or 
just  at  the  end  of  each  subsequent  convulsion.  If  the 
convulsions  are  so  severe  as  to  be  themselves  dangerous,  the 
inhalation  of  small  quantities  of  chloroform  is  sometimes  of 
great  service. 

If  there  is  much  diarrhoea  small  daily  doses  of  grey  powder 
at  night  combined  wdth  the  washing  out  of  the  colon  with  a 
long  soft  tube  is  excellent  practice. 

The  treatment  of  broncho-pneumonia  and  acute  bronchitis 
must  proceed  along  ordinary  general  lines. 

To  sum  up,  the  most  important  part  of  the  treatment  of 
w^hooping-cough  is  the  scrupulous  care  of  the  patient  for  some 
six  weeks,  the  care  to  be  as  scrupulous  in  the  early  stages  as 
in  the  acute,  and  also  as  scrupulous  during  the  stage  of 
decrudescence  as  in  the  acute.  Fatal  complications  may  arise 
as  the  result  of  carelessness  towards  the  end  of  an  attack,  just 
as  they  do  occur  as  the  result  of  carelessness  at  the  beginning 
of  an  attack. 

Diet. — The  diet  in  whooping-cough  depends  entirely  on 
the  severity  of  the  case.  In  a  mild  uncomplicated  case  with 
no  fever,  where  the  paroxysms  are  few,  no  alteration  in  diet 
is  necessary.  If  part  of  a  meal  is  vomited  the  child  is  usually 
ready  as  soon  as  the  paroxysm  is  over  to  eat  again,  and  he 
should  always  be  allowed  to  do  so.  "Where  the  paroxysms  are 
severe,  and  especially  if  there  be  some  pulmonary  complica- 
tion, it  is  better  to  feed  the    patient    frequently,   if    possible 


410  Chapter  XXIV. 

always  after  a  paroxysm,  with  small  quantities  of  fluid  or 
semi-fluid  food.  Milk,  whey,  a  little  clear  soup,  and  light, 
"easily  digested  milk  foods  will  be  found  to  be  best  in  such 
cases.  If  there  is  evidence  of  much  gastro-intestinal  irritation 
it  is  well  to  feed  the  patient  entirely  on  peptonised  milk  and 
barley  water  until  the  gastro-intestinal  symptoms  liaA'e  passed. 
The  addition  of  lime  water  to  the  milk  often  serves  to  lessen 
the  tendency  to  acidity  in  the  stomach.  In  some  cases  it  will 
be  found  that  a  fluid  diet  tends  to  produce  flatulence  and 
gastric  distension.  In  these  cases  it  is  best  to  allow  the 
patient  some  soft  solids,  such  as  porridge,  gruel,  bread  and 
milk,  or  rusks  soaked  in  milk.  Any  solid  food  which  has 
irritating  crumbs  will  naturally  be  bad  for  the  patient  and 
encourage  a  paroxysm.  As  convalescence  approaches  and  the 
paroxysms  become  less  frequent  a  gradual  resumption  of  the 
diet  normal  to  the  age  of  the  child  should  be  encouraged. 

It  is  occasionally  necessary  to  employ  rectal  feeding  in 
cases  who  refuse  food  or  whose  digestive  condition  is  such  as 
to  make  it  necessary  to  give  the  stomach  a  rest  for  a  short 
time. 

Epidemiology. — Whooping-cough  is  practically  endemic 
in  all  our  larger  cities.  It  is  more  common  and  more  severe 
in  the  so-called  temperate  climates  than  in  warmer  countries, 
but  it  has  been  carried  practically  all  over  the  world.  It 
tends  to  occur  from  time  to  time  in  vridespread  epidemic  form, 
and  has  a  seasonal  prevalence  during  the  spring  months,  which 
vary  from  February,  March,  and  April  in  the  south  of 
England  to  April,  May,  and  June  in  Scotland. 

While  whooping-cough  is  undoubtedly  a  specific  disease, 
its  bacteriology  remains  in  doubt.  Various  organisms  have 
been  described  as  the  causative  agent.  Afanassieff  claimed 
to  produce  symptoms  exactly  resembling  whooping-cough  by 
the  injection  into  the  windpipe  of  dogs  and  rabbits  of  cultures 
of  an  elongated  bacillus  isolated  from  the  bronchial  mucus  of 
patients  suffering  from  whooping-cough.  vSimilarly,  Eitter 
cultivated  a  small  diplococcus  which  occurred  largely  in 
chains,  and  claimed  to  be  able  to  produce  whooping-cough  in 
the  dog  by  injection  of  these  cultures  into  the  trachea.     The 


Whooping -Cough.  411 

dog,  however,  is  a  bad  subject  for  experiment  in  this  disease, 
as  it  is  evident  that  the  injection  of  many  organisms  into 
the  dog's  trachea  will  produce  paroxysmal  cough.  JJordet 
and  Gengou  claim  also  to  have  produced  whooping-cougli  in 
young  animals  by  inoculation  witli  a  short  bacillus  which  they 
isolated  from  the  broncliial  secretion  of  persons  suffering  from 
whooping-cougli.  This  organism,  they  state,  is  most  likely 
to  be  found  in  the  early  stages  of  the  disease.  At  the  present 
moment,  however,  complete  confirmation  of  the  discovery  of 
the  specific  virus  of  whooping-cough  is  needed. 

There  is  no  doubt  that  the  infection  of  whooping-cough 
is  spread  by  the  nasal,  pharyngeal  and  tracheal  or  bronchial 
secretion  of  the  patient.  Discharges  from  the  nose  and  the 
sputum  are  undoubtedly  infectious.  It  is  said  by  some  that 
whooping-cough  is  infectious  only  in  the  catarrhal  stage,  but 
it  would  seem  more  likely  that  the  patient  is  infectious  until 
defervescence  of  the  attack  is  well  advanced. 

Whooping-cough  attacks  for  the  most  part  very  young 
children.  The  vast  majority  of  patients  attacked  are  under 
four  years  of  age,  and  it  is  quite  common  to  find  infants  of 
sis  mouths  to  a  year  subjects  of  the  disease.  "When  it  attacks 
adults  it  is  seldom  a  dangerous,  though  always  a  troublesome 
disorder,  although  when,  as  sometimes  happen,  it  attacks  a 
person  who  is  elderly,  it  may  be  dangerous  on  account  of  the 
strain  thrown  upon  a  heart  and  arteries  which  have  already 
shown  signs  of  degeneration. 

Death  Rate. — The  hospital  death-rate  in  whooping-cough 
is  always  A^ery  high,  since  whooping-cough  is  not  a  notifiable 
disease,  and  only  children  of  the  poorest  classes  are  as  a  rule 
sent  to  hospital,  and  often  not  until  they  have  developed  siich 
complications  as  make  them  dangerously  ill.  Johnston  has 
given  the  mortality  rate  in  Glasgow  as  35  per  cent,  up  till 
two  years  of  age,  22  per  cent,  between  two  and  three,  12  per 
cent,  between  three  and  four,  8  per  cent,  between  four  and 
five,  and  6  per  cent,  between  five  and  ten  years.  Taken  over 
all,  the  hospital  deatli-rate  varies  as  a  rule  somewhere  between 
11  and  18  per  cent.  While  this  death-rate  is  large,  it  must 
be  remembered  that  it  applies  only  to  the  slum  inhabitants 


412  Chapter  XXIV. 

of  most  of  our  cities ;  it  is  not  veiy  common  for  children  of 
the  better  classes  to  die  of  the  disease.  The  high  death-rate 
in  our  towns  depends  upon  the  miserable  and  ill  nourished 
condition  of  the  children  attacked,  and  the  lack  of  care  which 
thev  receive  both  from  their  parents  and  the  community  in 
the  early  stages  of  the  illness. 

Home  Prophylaxis. — All  patients  suffering  from  whoop- 
ing-cough should  be  isolated,  and  in  time  of  epidemic  all 
children  who  suffer  from  a  febrile  catarrh  should  be  isolated 
on  suspicion.  Patients  should  be  kept  isolated  for  six  weeks 
after  the  paroxysmal  stage  has  become  definite,  or  until  the 
whoop  has  disappeared.  If  the  child  has  suffered  from 
broncho-pneumonia  it  may  be  better  to  isolate  him  until  the 
whoop  has  disappeared,  even  if  the  period  should  exceed  that 
of  six  weeks.  The  attendant  in  the  sick-room  should  always 
wear  an  overall,  which  should  be  left  in  the  room  when  she 
leaves  it.  The  discharges  of  the  patient  should  be 
disinfected,  spittoons  should  be  used  to  receive  the 
expectorated  mucus,  and  this  mucus  must  be  disinfected 
before  being  thrown  out.  All  handkerchiefs  and  clothing  in 
contact  with  the  patient  should  be  soaked  in  suitable  disin- 
fectant fluid  and  boiled  before  being  sent  to  the  wash.  The 
sick-room  should  be  fumigated  with  sulphur  or  sprayed  with 
formalin,  and  thoroughly  aired  and  washed  down  at  the 
conclusion  of  the  case.  It  is  not  necessary  to  re-paint  or 
re-paper  a  room  after  the  occurrence  of  whooping-cough. 

Public  Health  Administration. — It  is  difficult  to  lay  down 
any  rules  with  regard  to  the  public  health  administration 
of  whooping-cough,  seeing  that  the  disease  is  not  notifiable. 
On  the  occurrence  of  an  epidemic,  hoM-ever,  it  is  wise  to  send 
as  many  patients  to  hospital  as  possible,  especially  from  the 
poorer  and  more  crowded  districts  of  the  city,  and  it  would 
seem  reasonable  to  suggest  that  during  an  epidemic  of  any 
size  the  visiting  of  the  areas  which  are  most  crowded  and 
in  which  most  cases  are  arising  should  be  undertaken  at  least 
in  some  measure  by  some  of  the  health  office  staff.  In  this 
way  it  would  be  possible  to  lessen  the  mortality  rate  bj 
supervision  and  advice  while  the  disease  is  acute,  and  by  the 


Whooping -Cough.  413 

encouragement  of  parents  to  take  great  care  of  tlie  cliildren 
who  are  in  an  early  stage  of  tlie  disease.  Sclirtols  in  tlie 
district  sliould  be  examined  daily,  and  any  child  suffering 
from  catarrh  should  be  sent  home  and  not  allowed  to  attend 
school  until  such  time  as  is  evident  that  he  is  not  the  subject 
of  whooping-cough.  It  is  doubtless  impossible  at  the  present 
moment  to  attempt  anything  like  the  notification  of  whooping- 
cough,  as  the  proper  accommodation  for  this  disease  and  for 
measles  would  tax  the  already  over-burdened  ratepayer  to  a 
degree  impossible  of  toleration.  But  the  removal  of  as  many 
cases  as  possible  to  hospital  during  an  epidemic  should  be 
seriously  encouraged. 


ACUTE    DISEASES    FREQUENTLY 

ATTRIBUTED    TO    A    DIET    CONSISTING 

LARGELY    OF    CERTAIN    CEREALS. 


Chapter  XXV. 

BERIBEEI. 

Synonym :     Kakke. 

Definition. — A  disease  wliicli  occurs  eudemically  and 
epidemically  in  tropical  and  sub-tropical  climates, 
characterised  by  a  specific  multiple  neuritis,  and  a  notable 
tendency  to  cardiac  failure;  sometimes  associated  with  cedema. 

Incubation  Period. — The  incubation  period  of  beriberi  has 
not  yet  been  definitely  established,  and,  according  to  different 
observers,  is  variously  stated  to  be  somewhere  between  a  few 
weeks  and  several  months. 

Rash. — Xo  rash  has  been  noted  as  typical  of  the  disease. 

Clinical  Types. — Speaking  roughly,  there  are  two  distinct 
types  of  beriberi;  one  which  is  characterised  by  extreme 
wasting  of  muscles  and  notable  loss  of  fat,  so  that  the  patients 
appear  extremely  shrivelled  and  emaciated,  and  the  other  in 
which  there  is  also  weakness  of  muscles,  but  in  which,  at  the 
outset  at  any  rate,  the  patient  is  the  subject  of  very  marked 
oedema  of  the  limbs,  and  perhaps  of  the  whole  body.  The 
first  class  has  been  called  "  dry  beriberi,"  the  second  "  wet 
beriberi." 

The  onset  of  the  disease  is  as  a  rule  gradual,  but  in  some 
cases  the  condition  develops  with  great  rapidity.  The 
patient  first  of  all  complains  of  weakness,  aching  in  the  legs, 
palpitation  and  breathlessness.  In  some  cases  the  legs  or 
face  become  gradually  oedematous  in  addition  to  these 
sjanptoms. 

Dry  beriberi :  In  this  form  of  the  disease,  when  the 
patient  becomes  ill  enough  to  seek  advice,  there  is  marked 
wasting  of  the  muscles  of  the  legs,  and,  although  to  perhaps 


Beriberi,  415 

a  lesser  extent,  of  the  iirms.  The  calves  are  sliruiiketi  iiud 
flabby,  the  muscles  of  tlie  tliigh  are  soft  and  wasted,  the 
thenar  and  hypothenar  eminences  also  show  atrophy,  and  tlie 
muscles  of  the  arm  generally  are  weak,  flabby,  and  slirunken. 
Deep  pressure  over  the  affected  muscles  elicits  a  considerable 
degree  of  tenderness.  The  deep  reflexes  are  diminished  or 
absent;  the  muscles  quite  early  in  the  disease  tend  to  exhibit 
the  reaction  of  degeneration  on  being  tested  electrically;  the 
superficial  reflexes  are  present,  and  are  sometimes  very  active. 
There  is  as  a  rule  no  interference  with  the  function  of  the 
sphincters.  The  hands  and  limbs  are  ataxic,  so  that  when 
the  patient  tries  to  walk  his  gait  exhibits  a  great  deal  of 
muscular  inco-ordination,  and  similarly  any  finer  movements 
of  the  hands  and  fingers  are  performed  with  great  difficulty 
and  fumbling.  The  movements  of  the  hands  and  limbs  are 
difiicult,  not  only  on  account  of  the  ataxia,  but  on  account 
of  the  great  degree  of  muscular  weakness  which  is  present. 
The  patient  may  be  quite  unable  to  raise  the  limbs  in  bed, 
and  the  fumbling  and  difficulty  in  connection  with  the  finer 
movements  of  the  hands  is  as  much  due  to  loss  of  muscular 
power  as  to  real  ataxia.  There  is  no  tremor  of  the  hands. 
Ankle  drop  is  common.  It  is  not  usual  to  find  atrophy  of 
the  muscles  of  the  face,  the  ocular  muscles,  the  muscles  of 
mastication,  or  the  muscles  of  the  tongue  or  pharynx.  Besides 
the  loss  of  power  and  wasting  in  the  muscles  a  certain  amount 
of  anaesthesia  of  the  skin  is  very  common,  particularly  over 
the  front  of  the  shins,  the  thighs,  the  dorsum  of  the  foot, 
and  the  finger  tips.  This  ansesthesia  also  contributes  to  the 
general  inco-ordination  of  the  patient's  movements.  The 
condition  is  thus  evidentlj^  due  to  a  multiple  neuritis. 

The  tongue  is  as  a  rule  clean,  the  urine  presents  no 
abnormality,  and  the  bowels  are  fairly  active.  There  is 
frequently,  however,  some  feeling  of  distention  and  oppression 
in  the  epigastric  region  after  a  meal. 

In  some  cases  no  other  symptoms  than  those  mentioned 
present  themselves,  but  in  the  majority  of  patients  who  are 
affected  with  beriberi,  even  of  the  dry  type,  there  is  greater  or 
lesser  cardiac  distress.     The  patient  suffers  from  breathlessness 


416  Chapter  XXV. 

ou  exertion,  and  also  from  palpitation.  Tlie  pulse  tends  to  be 
soft  and  rapid,  and  the  carotids  throb  violently.  On 
examination  of  the  chest  the  apex  impulse  is  found  to  be 
diffuse,-  and  epigastric  pulsation  is  veiy  common.  On 
percussion,  the  area  of  prtecordial  dullness  is  usually  enlarged, 
especially  to  the  right,  and  this  enlargement  may  be  very 
considerable.  On  auscultation,  systolic  murmurs  may  be 
audible,  either  at  the  apex,  in  the  tricuspid  area,  or  at  the 
base  of  the  heart,  sometimes  in  all  three  situations. 
Reduplication  of  the  first  sound  at  the  apex  and  of  the  second 
sound  at  the  base  is  very  common,  and  the  ventricular  sounds 
are  sharp  and  slapping,  while  the  long  pause  is  noticeably 
shortened,  so  that  the  heart's  sounds  are  equally  distant  from 
■each  other,  and  resemble  the  ticking  of  a  clock.  The  degree 
of  cardiac  distress  varies  very  much  in  different  cases,  and 
may  vary  considerably  from  day  to  day  in  the  same  case. 
The  murmurs  are  not  always  audible,  but  may  be  present  one 
day  and  absent  the  next.  The  degree  of  cardiac  dilatation 
is  also  inconstant,  and  daily  observations  will  show  consider- 
able variation  in  the  extension  of  the  prsecordial  area  of 
dullness  to  right  or  left. 

The  disease  may  clear  up  within  a  few  days  of  its 
appearance,  and  leave  the  patient  perfectly  well,  or  it  may 
run  a  protracted  course,  lasting  for  months.  Throughout  the 
attack  acute  cardiac  failure  is  liable  to  occur,  so  that  the 
patient  may  die  suddenly  of  syncope,  or  may  be  seized  by 
urgent  dyspnoea  and  become  cyanosed,  suffering  from  cardiac 
distress  and  pra3cordial  and  epigastric  pain.  The  pulse  is 
rapid,  feeble  and  irregular,  the  extremities  are  cold,  and 
death  may  occur  after  a  few  hours  of  suffering  and  struggling, 
(Edema  of  the  lungs  is  common  in  such  cases,  and  effusion 
into  the  pleura  or  pericardium  may  also  occur.  In  certain 
cases  death  may  ensue  as  the  result  of  a  paralysis  of  the 
diaphragm  and  intercostal  muscles,  but  in  most  instances 
death  is  due  to  cardiac  failure,  more  or  less  rapid. 

When  recovery  takes  place  it  is  usually  slow.  The 
wasting  of  the  muscles  is  arrested,  hyperalgesia  disappears, 
the  limbs  become  fuller,   muscular  power  gradually  returns. 


Beriberi.  417 

and  the  deep  reflexes  reappear,  llecovery  is  in  most  instances 
complete,  although  in  some  cases  there  may  be  a  permanent 
atroj)liy  of  certain  groups  of  muscles  in  the  arm  or  leg,  with 
resulting  deformity,  or  the  patient  may  suffer  from  a. 
permanently  weakened  and  dilated  heart. 

While  the  onset  of  the  disease  is  usually  gradual  it  some- 
times happens  that  a  patient  who  has  gone  to  bed  quite  well 
may  waken  up  in  the  morning  with  marked  paresis  of  his- 
limbs,  and  thereafter  the  disease  may  progress  with  great 
rapidity. 

Wet  beriberi  :  In  this  type  of  the  disease  the  striking^ 
feature  is  a  marked  oedema  of  the  face,  hands  and  feet. 
The  patient  is  usually  very  short  of  breath,  and  the  lips  and 
face  may  be  slightly  cyanosed.  He  bears  a  superficial 
resemblance  to  an  ordinary  case  of  acute  nephritis,  but, 
although  the  urine  is  usually  dark,  scanty,  and  of  high  specific 
gravity,  it  contains  no  blood,  and  albumin  is  usually  absent, 
or  if  present,  it  appears  as  a  mere  trace.  The  oedema,  too,  is- 
distinctly  firmer  than  that  which  is  met  with  in  nephritis, 
and  in  many  cases  does  not  involve  the  scrotum. 

Examination  of  the  heart  reveals  signs  of  dilatation  and 
weakness;  slight  effusion  into  the  pleura  is  quite  common, 
and  a  certain  amount  of  oedema  of  the  lungs  is  not 
infrequent. 

The  deep  reflexes  are  diminished  or  absent;  "  dropped 
ankle  "  is  common,  and  on  firm  pressure  over  the  calf  muscles 
it  will  be  found,  in  most  cases,  that  they  are  hyperalgesic. 
A  certain  amount  of  anaesthesia  of  the  skin  over  the  shins  and 
finger  tips  is  usually  present.  The  patient  commonly 
complains  of  a  feeling  of  distress  referred  to  the  prsecordial 
region  and  epigastrium,  and  this  distress  is  usually  aggravated 
by  the  taking  of  food.  The  urine,  as  has  been  indicated,  is 
dark  coloured  and  very  scanty;  indeed,  in  many  cases  only 
a  few  ounces  are  passed  in  the  twenty-four  hours.  It  will 
be  seen  that  in  cases  of  this  kind  the  patient  suffers  from  a 
peripheral   neuritis,   with,    in   addition,    an   oedema  which   is 


418  Chapter  XXV. 

firmer  than  that  which  is  usually  met  with  iu  acute  nephritis, 
and  which  is  probably  not  entirely  cardiac  in  origin.  The 
amount  of  oedema  present  may  be  much  less  than  has  been 
described  above,  and  may  be  limited  to  the  front  of  the  legs, 
ankles  and  feet,  with  perhaps  a  little  in  the  flanks  and  sacral 
region.  Where  the  cedema  is  limited,  the  typical  atrophy 
of  muscles  is,  of  course,  more  apparent.  Sometimes  the 
oedema  is  very  limited  and  transient,  so  that  it  is  not 
apparent  except  on  careful  examination. 

Patients  suffering  from  "wet"  beriberi  are  more  liable 
to  sudden  and  severe  attacks  of  cardiac  failure  than  those  who 
suffer  from  the  "  dry  "  type  of  the  disease.  In  most  cases 
which  recover  the  cedema  disappears,  leaving  the  patient 
wasted  and  shrunken,  as  has  been  described  in  cases  of  "  dry  " 
beriberi,  and  convalescence  progresses  in  a  similar  way. 

The  temijerature  is  not  elevated  at  any  stage  of  the 
disease,  either  in  the  "  wet"  or  the  "  dry  "  type. 

Sequelae. — The  most  important  sequelae  of  beriberi  are, 
as  has  been  mentioned  before,  'permanent  loeal^ness  of  the 
cardiac  muscle  and  permanent  atropliy  of  one  or  more  groups 
of  muscles.  F'ortunateh'',  such  sequelse  are  not  very  common; 
recovery  is  usually  complete,  although  convalescence  is  often 
very  protracted. 

Diagnosis. — As  a  rule,  the  diagnosis  of  beriberi  is  not  a 
difficult  matter.  Epidemics  of  multiple  peripheral  neuritis 
occurring  in  a  place  or  ship  in  which  similar  epidemics  have 
arisen  before  are,  in  the  absence  of  any  definite  evidence  of 
wholesale  arsenical  poisoning,  almost  certainly  due  to  beriberi. 
If,  in  addition  to  the  ordinary  signs  of  peripheral  neuritis, 
there  is  a  tendency  for  cedema  and  cardiac  disturbance  to 
appear  in  a  certain  proportion  of  the  cases,  the  diagnosis  of 
beriberi  is  the  more  certain.  Where  the  attack  of  beriberi 
is  mild  it  is  frequently  diagnosed,  by  those  who  have  not 
had  much  experience  of  the  disease,  as  a  "rheumatic"  or 
"  malarial"  affection,  more  particularly  as  in  mild  attacks  the 
patient  complains  merely  of  a  little  weakness  and  pain  in 
tlie  legs,  and  any  cedema  that  is  present  is  so  slight  as  not 
to  be  apparent  except  on  very  careful  examination.  In  the 
tropics   any  person  who   complains   of  pain   in  the  legs   and 


Beriberi.  419 

shows  a  little  anaesthesia  and  (jodema  over  tlie  front  u\  llie 
shins  should  be  carefully  examined,  and  if  hyperalf^csia  of 
the  muscles  of  the  calf  is  discovered  and  the  knee  reflexes  are 
found  to  be  diminished  or  absent,  the  case  should  be  looked 
upon  as  beriberi,  and  dealt  with  accordingly. 

It  is  to  be  remembered  that  even  in  cases  of  beriberi  wljich 
are  very  slight  as  regards  paresis  and  ccdema,  sudden  cardiac 
failure  may  occur,  and  it  is  imjDortant  to  recognise  the  disease 
even  when  its  manifestations  are  apparently  very  mild,  on 
account  of  the  possibility  of  a  fatal  termination  to  a  case 
whose  symptoms,  other  than  cardiac  disturbance,  may  be  so 
slight  as  easily  to  escape  notice. 

Sporadic  cases  are  apt  to  be  attributed  to  alcoholism, 
malaria  or  poisoning  by  arsenic,  on  account  of  the  history 
of  the  patient,  and  such  sporadic  cases  are  doubtless  frequently 
missed. 

During  an  epidemic,  too,  it  is  sometimes  difficult  to 
separate  cases  of  beriberi  from  cases  of  perij)heral  neuritis 
which  occur  from  quite  other  causes. 

Treatment. — A  patient  suffering  from  beriberi  should  be 
removed  at  once  from  the  house  or  ship  in  which  he  probably 
contracted  the  disease,  and  should  be  put  to  bed  and  kept 
there  strictly  until  convalescence  is  so  far  established  as  to 
make  the  occurrence  of  cardiac  failure  at  least  iraprobable. 
It  is  important  that,  although  the  patient  is  in  bed,  he  should 
have  abundance  of  fresh  air,  and,  if  possible,  sun-light,  so 
that  the  verandah  of  tlie  hospital  is  a  suitable  place  for  him 
to  spend  at  least  the  day-time. 

Cardiac  failure  must  be  dealt  with  in  the  usual  way,  and 
strychnine  has  been  recommended,  combined  with  small  doses 
of  digitalis  or  strophanthus.  Where  acute  cardiac  distress 
appears  with  much  cyanosis,  nitro-glycerine  and  nitrite  of 
amyl  should  be  given,  and  bleeding  has  frequentlj^  served  to 
relieve  a  greatly  embarrassed  right  heart.  The  bleeding 
should  be  just  sufficient  to  relieve  temporary  distress,  and 
may  be  repeated  should  the  attacks  recur,  as  they  most 
usually  do.  The  inhalation  of  oxygen  is  also  recommended 
in  such  cases.  In  any  case  where  there  is  much  cardiac 
distress  the  possibility  of  its  being  due  to  a  pleural  effusion 


420  Chapter  XX  V. 

should  be  lemeinbered,   and   any  fluid  present  in  the  pleura 
should  be  drawn  otl:. 

Where  there  is  much  wasting  of  the  muscles  it  is 
necessary  to  be  very  careful  to  avoid  the  possibility  of 
permanent  deformity.  This  is  particularly  necessary  where 
the  foot  is  '"dropped,"  and  in  such  cases  it  is  well,  as  in 
infantile  palsy,  to  correct  the  deformity  by  means  of  a  splint. 
The  wasted  muscles  should  be  treated  by  massage  and  mild 
faradism  as  soon  as  the  hyperalgesia  of  the  muscles  has 
subsided,  and  repeated  small  doses  of  strychnine  given 
hypodermically  are  also  recommended  at  this  stage  of  the 
disease. 

As  convalescence  is  established  a  complete  change  of 
scene  is  useful,  and  where  at  all  possible,  the  patient  ought 
not  to  return,  for  some  time  at  least,  to  a  region  where 
beriberi  is  prevalent,  since  the  return  to  such  a  district  too 
early  often  induces  a  relapse. 

Diet. — In  beriberi  the  diet  should  be  fairly  generous,  but 
great  care  must  be  taken  not  to  overload  the  stomach  at  any 
meal.  It  is  important  that  the  patient  should  have  a  good 
proportion  of  nitrogenous  food  and  fat  in  his  dietary.  Milk 
and  eggs  and  a  certain  amount  of  meat  ought  to  be  given. 
Eice,  on  account  of  its  bulk,  is  not  a  very  suitable  article  of 
diet  for  those  suffering  from  beriberi,  and  should  be  replaced 
as  far  as  possible  by  bread  and  oatmeal.  In  severe  cases  with 
a  tendency  to  cardiac  disturbance  it  may  be  necessary  to  limit 
the  diet,  at  any  rate  during  the  period  of  distress,  to  milk 
and  beaten-up  eggs. 

Epidemiology. — Beriberi  is  endemic  in  certain  tropical 
and  sub-tropical  districts,  particularly  in  the  Malay  Peninsula, 
China,  Japan,  and  certain  districts  in  India  and  Africa.  It 
has  been  seen  among  the  natives  in  Western  Australia,  and 
it  exists  in  Brazil,  in  which  country  an  extensive  epidemic 
prevailed  between  1860  and  1865.  Cases  have  been  reported 
from  Lake  Nyassa,  from  the  Congo,  Uganda,  the  West  Indian 
Islands  and  the  Sandwich  Islands.  An  epidemic 
indistinguishable  from  beriberi  broke  out  within  late  years 
in  the  Richmond  Asylum,  Dublin,  and  a  similar  disease  has 
been  seen  in  lunatic  asylums  in  the  United  States  of  America 
and  in  France. 


Beriberi.  421 

The  disease  prevails  in  districts  wliich  are  damp  and  hot. 
In  those  regions  whicli  have  no  cold  season  the  epidemic 
prevalence  of  beriberi  is  greater  about  the  time  of  the  rains. 
In  countries  where  there  is  a  hot  and  a  cold  season  the  epidemic 
prevalence  is  greater  in  the  hot  season,  while  during  the  cold 
season  new  cases  do  not  appear  and  old  cases  tend  to  recover. 
The  disease  seems  most  readily  to  attack  those  who  sleep  near 
the  ground.  It  is  common  alike  in  large  cities  and  among 
the  rural  population.  It  has  no  apparent  connection  with 
standing  water,  swamps,  or  running  water,  so  that  it  is 
unlikely  that  it  is  associated  with  the  presence  of  mosquitoes 
or  other  biting  flies.  Overcrowding  and  lack  of  cleanliness 
seem  to  encourage  the  spread  of  beriberi,  and  it  is  particularly 
common  in  the  East  in  gaols,  schools,  coolie  camps  and  armies. 
It  is  also  frequently  met  with  in  the  overcrowded  and  unclean 
forecastles  of  eastern-going  ships. 

The  disease  attacks  both  children  and  adults,  and  both 
sexes  are  affected. 

Like  malaria,  the  disease  may  remain  latent  in  the  person 
attacked  for  a  long  time,  and  it  is  quite  common  to  find  Lascars 
and  other  members  of  ships'  crews  developing  beriberi  months 
after  they  have  left  regions  in  which  it  was  possible  for  them 
to  contract  the  disease. 

Method  of  Infection. — No  micro-organism  has  been 
discovered  which  can  be  said  to  be  the  cause  of  beriberi. 
Various  bacteria  have  been  described  as  having  been  found  in 
cases  suffering  from  this  disease,  but  they  have  afterwards 
proved  to  be  organisms  of  a  non-pathogenic  character. 

Various  theories  have  been  propounded  regarding  the 
cause  of  beriberi,  and  the  theory  which  has  persisted  most 
firmly  up  to  the  present  time  is  that  it  is  in  some  way  due 
to  feeding  on  certain  kinds  of  rice.  It  has  been  supposed 
by  some  that  the  disease  arises  as  the  result  of  eating  rice 
w^hich  is  mouldy  or  otherwise  deteriorated,  and  it  has  also 
been  suggested  that  it  is  caused  by  a  diet  which  consists  almost 
exclusively  of  polished  rice,  that  is  to  say,  rice  which  has 
been  deprived  of  the  brown  nitrogen-containing  layer  which 
exists  between  the  white  central  portion  of  the  grain,  which 


422  Chapter  XXV. 

we  iu  this  country  eat  as  rice,  aud  the  enveloping  husk. 
Experiments  have  been  made  in  certain  phices  with  the  object 
of  showing  that  natives  who  feed  entirel}^  on  brown  rice, 
that  is  to  say,  rice  which  has  not  been  deprived  of  the 
nitrogenous  layer,  do  not  contract  beriberi,  while  those  who 
feed  on  polished  rice  are  frequentl}'^  attacked  by  the  disease. 
In  certain  coolie  camps  it  is  maintained  that  the  admixture  of 
a  certain  proportion  of  brown  rice  with  the  polished  rice  which 
the  coolies  prefer,  is  sufficient  to  prevent  the  occurrence  of 
beriberi  in  anything  like  serious  epidemics.  Some  observers 
have  stated  that  Eastern  people,  who,  while  at  home,  eat 
brown  rice,  are  in  the  habit  of  taking  polished  rice  with  them 
for  food  w4ien  they  go  on  a  journey,  and  that  during  the 
time  that  their  diet  consists  of  polished  rice  they  are  liable 
to  be  attacked  by  beriberi.  Those  who  have  made  these 
statements  believe  that  the  disease  is  the  result  of  nitrogen 
starvation,  due  to  the  removal  of  the  brown  layer  of  the  rice 
which  is  of  high  nitrogen  value. 

It  is  difficult  to  say  how  this  theory  can  hold  good,  seeing 
that  the  disease  attacks  rich  and  poor  in  the  East,  that  is 
to  say,  it  attacks  those  who  live  almost  entirely  on  rice,  and 
those  whose  dietary,  in  respect  of  nitrogen,  is  at  least  as  rich 
as  that  of  a  poor  European. 

Experiments  have  been  made  on  the  feeding  of  rats  on 
polished  rice,  and  some  observers  have  noted  that  among 
rats  fed  in  this  way  a  disease  similar  to  beriberi  has  appeared. 
In  1909  I  carried  out  some  feeding  experiments  in  the 
University  of  Glasgow,  during  the  course  of  which  I  fed  a 
number  of  rats  on  a  diet  which  consisted  entirely  of  boiled 
rice.  The  result  of  the  experiments  was  roughly  as  follows  :  — 
The  rats,  wdio  ate  large  quantities  of  rice,  maintained  their 
weight,  and  even  increased  it,  and  all  the  time  of  the 
experiment  stored  nitrogen  to  a  certain  extent.  Their  general 
condition,  however,  deteriorated  considerably.  The  females 
died  in  child-birth  or  shortly  before  full  term,  while  the 
males,  after  a  period  of  apparent  health  which  lasted  for  many 
weeks,  became  infected  with  ordinary  pyogenic  organisms, 
and  died  of  abscesses  in  the  subcutaneous  cellular  tissue,  the 


I 


Beriberi.  423 

liver,  or  the  lungs.  The  rats  were  kept  singly  in  metabolic 
cages,  and  their  cleanliness  was  scrupulously  attended  to.  In 
none  of  the  rats  was  there  any  hint  of  paresis  of  legs  or  any 
sign  of  nerve  degeneration. 

The  features  common  to  the  surroundings  of  all  those 
who  suffer  from  beriberi  are  overcrowding,  heat,  damp  and 
lack  of  cleanliness.  On  ship-board  beriberi  is  not  invariably 
confined  to  the  rice-fed  crews  of  Eastern  extraction,  whether 
Mongolian  or  Lascar  in  type,  but  is  also  met  with  among 
European  sailors,  and  even  among  the  ship's  officers,  who 
are  not  in  the  habit  of  confining  themselves  to  a  dietary  of 
rice.  I  recollect  three  cases  of  beriberi  which  were  brought 
to  hospital  in  Glasgow.  The  patients  were  all  Frenchmen, 
and  were  sailors  on  board  a  small  cargo  steamer  which  had 
just  returned  from  South  America.  On  inquiring  into  the 
history  of  the  ship  it  was  found  that  on  her  previous  voyage 
she  had  been  East,  and  on  the  voyage  home  beriberi  had 
broken  out  in  the  forecastle.  She  discharged  her  cargo  in 
France,  shipped  a  new  crew,  and  went  out  to  South  America. 
On  the  return  voyage  to  Glasgow  beriberi  again  broke  out, 
and  the  three  cases  were  sent  to  hospital.  In  this  group  of 
cases  there  could  be  no  suggestion  that  the  disease  was 
produced  by  the  eating  of  rice,  infected  or  uninfected,  but  on 
examination  of  the  ship  the  forecastle  was  found  to  be 
unusually  dirty  and  stuffy.  Before  the  ship  was  permitted 
to  leave  port  the  forecastle  was  cleaned  by  the  sanitary 
authorities  in  a  way  in  which,  from  all  appearances,  it  had 
never  been  cleaned  before.  With  regard  to  these  three  cases 
it  will  be  seen  that  the  voyage  from  which  they  were  returning 
did  not  include  a  visit  to  places  where  beriberi  was  at  all 
prevalent,  and  the  occurrence  of  the  disease  on  two  consecutive 
voyages  in  the  same  ship  with  a  dirty  forecastle  suggests 
at  once  the  probability  that  the  disease  was  acquired  in  the 
forecastle,  and  not  through  any  errors  in  diet. 

A  diet  which  consists  largely  or  entirely  of  polished  rice 
is  of  low  nutritional  value,  and  it  may  be  that  people  who 
confine  themselves  to  such  a  diet  are  unusually  liable  to 
infection  by  any  organism,  and,  living  as  they  do  in  districts 
in  which  beriberi  is  prevalent,  they  fall  victims  to  the  disease 

FF  2 


424  Chapter  XXV. 

more    easily  than    those   whose   dietary   is   more    varied   and 
ample. 

At  present  new  evidence  al]  goes  to  show  that  the  disease 
is  the  result  of  infection  by  a  specific  germ  which  is  conveyed 
to  man  by  some  intermediary,  of  the  nature  of  the  louse  or 
bug.  A  more  careful  and  detailed  study  of  the  endemic  habitat 
of  beriberi  is  necessary  before  one  can  be  absolutely  definite 
as  to  the  means  whereby  infection  is  conveyed  to  man,  but 
the  study  of  outbreaks  in  gaols  in  the  East  goes  to  show  that 
the  disease  will  persist  in  certain  gaols  despite  all  change  of 
diet,  while  other  gaols  remain  free  from  the  disease,  despite 
the  food  which  the  prisoners  eat.  Patients  taken  from  a 
healthy  to  an  unhealthy  gaol  will  develop  the  disease,  and 
prisoners  suffering  from  beriberi,  if  taken  from  an  unhealthy 
to  a  healthy  gaol,  tend  to  recover  after  their  transfer.  Evidence 
like  this  is  weighty,  and  is  absolutely  against  the  rice 
origin  of  beriberi ;  and  further,  reasoning  on  a  priori  grounds, 
it  w^ould  seem  to  be  a  very  curious  thing  if  beriberi  were  to  be 
left  as  the  only  specific  disease  in  our  nosology  due  to  a 
dietetic  fault  and  not  to  the  introduction  of  some  organic 
virus  into  the  system,  whether  directly  or  through  the 
mediation  of  some  insect  or  parasitic  vermin. 

Death  Rate.  — The  mortality  rate  of  beriberi  is  a  variable 
quantity,  and  it  varies  according  to  the  type  of  the  epidemic 
and  the  place  in  which  the  outbreak  occurs.  Speaking 
broadly,  the  death  rate  is  higher  in  low-lying  than  in  high 
districts,  in  acute  than  iii  chronic  cases,  and  in  those  cases 
which  are  dropsical  than  in  the  dry  or  atrophic  type  of  the 
disease.  Manson  gives  the  death-rate  as  varying  in  different 
places  and  in  different  epidemics  from  5  to  30  per  cent. 

Prophylaxis.  — As  beriberi  is  not  directly  contagious, 
strict  isolation  of  a  patient  is  not  absolutely  necessary  for 
the  benefit  of  the  community,  but  for  his  own  sake  he  should 
be  removed  as  speedily  as  possible  from  any  district  where 
the  disease  is  known  to  be  prevalent.  Especially  should  he 
be  removed  from  low-lying,  overcrowded  districts,  and  housed 
in  a  clean,  airy  building,  well  ventilated  and  situated  on 
some  elevation. 


Beriberi.  425 

Looking  upon  the  disease  as  due  to  some  organic  virus, 
possibly  of  a  protozoal  kind,  and  as  probably  carried  by  para- 
sitic vermin,  it  stands  to  reason  that  in  districts  where  beri- 
beri is  prevalent  sanitary  measures  with  regard  to  the  encour- 
agement of  cleanliness  and  the  prevention  of  overcrowding 
should  be  enforced  as  rigorously  as  the  prevailing  customs  of 
the  country  permit.  The  forecastles  of  eastern-going 
ships  should  be  repeatedly  cleaned,  not  superficially  but  very 
thoroughly,  woodwork  should  be  kept  in  strict  order,  so  that 
lice  and  other  vermin  may  have  little  harbourage,  and  suit- 
able disinfectants  should  be  freely  used.  When  the  disease 
breaks  out  on  board  ship  it  is  well  to  take  the  patient  from 
the  forecastle  and  keep  him  on  deck,  while  such  measures  of 
disinfection  of  the  forecastle  as  are  possible  at  the  time  ought 
to  be  undertaken  immediately. 

Where  it  is  possible,  for  example  in  coolie  camps,  the 
diet  of  the  community  in  which  the  disease  has  broken  out 
should  be  increased,  if  even  by  the  addition  of  brown  to 
white  rice,  and  also  by  the  introduction  of  fish  and  milk 
where  this  is  at  all  feasible.  As,  however,  the  disease  is 
endemic  in  cities  and  in  countries  which  are  notably  averse 
to  cleanliness  and  where  the  people  are  too  poor  to  afford  a 
very  liberal  or  varied  dietary,  it  is  a  matter  of  great 
difficulty  in  such  districts  to  enforce  any  measures  which  may 
be  effective  in  lessening  the  incidence  of  the  disease. 


426 


Chapter  XXVI. 

PELLAGRA. 

Synonyms. — The  Rose;  Alpine  scurvy;  Asturian  leprosy; 
Italian  scurvy, 

French  :  Maladie  des  Saints  Mains;  Galle  de  St.  Ignace. 

German  :  Der  Lombardische  Aussatz. 

Italian  :      Pellagra ;  mal  del  padrone;  mal  della  spienza ; 
scottatura  di  sole ;  mal  salso,  etc. 

Spanish  :  Mal  de  la  rosa;  mal  del  monte;  Flema  salada. 

Definition. — An  endemic  disease  characterised  by  a  group 
of  sj^mptoms  involving  the  skin,  the  gastro-intestinal  tract 
and  the  nervous  system.  The  disease  is  characterised  by 
periodic  exacerbations  and  remissions. 

Incubation  Period. — The  incubation  period  ol  pellagra  is, 
as  far  as  adults  are  concerned,  very  difficult  to  fix,  and  it  is 
probable  that  the  ordinary  period  of  incubation  described  is 
rather  long.  During  the  time  that  the  idea  held  more  or 
less  generally  that  the  disease  was  due  in  some  way  to  the 
eating  of  maize  the  incubation  period  was  put  down  as  some- 
thing approaching  several  months  in  duration.  Hecent 
investigation  has,  however,  shown  that  the  incubation  period 
may  be  very  much  shorter.  Sambon  has  seen  cases  in  infants 
as  young  as  three  months  old,  and  quotes  an  interesting 
case  of  a  child  born  in  a  gaol  in  Italy  of  a  non-pellagrous 
mother  and  in  a  non-pellagrous  district.  This  child  was  taken 
from  the  mother  when  it  was  five  months  old,  and  boarded 
out  with  strangers,  who  happened  to  live  in  a  notably  pella- 
grous district.  The  child  developed  pellagra  in  something 
like  a  fortnight,  so  that  in  this  case  the  incubation  period 


Pellagra.  427 

cannot  have  been  longer  than  a  fortnight.  It  is  f(uito  probable 
that  in  some  instances  it  may  be  less  than  a  week. 

Clinical  Types. — The  onset  of  pellagra  is  indicated  by  a 
feeling  of  general  malaise,  some  gastro-intestinal  disturbance, 
vertigo  and  the  appearance  of  the  characteristic  rash.  Tliig 
rash  appears  on  the  face  and  the  neck  above  the  collar,  and 
on  the  backs  of  the  hands;  in  other  words,  on  those  parts  of 
the  body  which  are  directly  exposed  to  light  and  air.  The 
rash  as  it  appears  at  first  resembles  frequently  an  ordinary 
sunburn;  the  skin  is  reddened  and  slightly  thickened  and 
inflamed.  In  some  instances  the  redness  and  inflammation 
are  associated  with  the  formation  of  a  bullous  eruption.  As 
the  disease  usually  makes  its  appearance  for  the  first  time  in 
spring  or  early  summer,  the  rash  is  very  frequently  mistaken 
for  ordinary  sunburn,  and  in  those  cases  where  the  other 
symptoms  are  slight  and  obscure  the  mistake  is  natural  enough. 
The  severity  of  the  rash  varies  very  much  in  different  cases. 
On  its  first  appearance  it  may  be  very  slight,  resembling 
closely  a  mild  degree  of  solar  erythema,  although  it  has  a 
slightly  different  distribution.  The  backs  of  the  hands  are 
usually  most  involved,  and  when  the  face  is  implicated  the 
forehead  and  cheeks  are  most  definitely  attacked.  The  erup- 
tion on  the  ears  is  not  so  marked.  The  appearance  of  the 
rash  on  the  neck  is  very  variable;  in  a  great  many  cases  the 
neck  is  not  attacked  at  all,  but  when  the  rash  does  appear  in 
this  region  it  has  a  collar-like  distribution  which  is  very 
characteristic.  A  solar  erythema  is  not  so  selective;  the  neck 
and  the  ears  are  affected  equally  with  the  face  and  hands. 
The  eruption  of  pellagra  may  also  affect  the  forearms,  the 
legs  and  the  upper  part  of  the  chest,  if  these  regions  have 
been  exposed  freely  to  light.  The  parts  affected  by  the  rash 
are  irritable  and  burning.  Sometimes  petechias  are  present, 
although  the  eruption  is  usually  of  a  frankly  erythematous 
kind. 

The  degree  of  implication  of  the  gastro-intestinal  tract  is 
also  very  variable.  Some  cases,  indeed,  may  present  no 
symptoms  referable  to  the  digestive  tract ;  in  others  there 
may  be  only  a  slight  furring  of  the  tongue  and  a  slight  feeling 
of  oppression  in  the  epigastrium,  associated  with  eructations 


428  Chapter  XXVI. 

of  gas,  while  in  many  cases  tliere  is  quite  marked  distention 
of  the  epigastrium  and  lower  part  of  the  abdomen,  and 
the  patient  suffers  considerable  pain  in  these  regions,  especially 
after  food.  The  appetite  is  usually  rather  capricious.  Some- 
times the  tongue  is  very  thickly  coated  at  the  onset  of  the 
attack,  but  as  the  attack  proceeds  it  loses  its  epithelium  and 
becomes  raw  looking  and  sore,  while  at  the  same  time  the 
patient  complains  of  a  continual  salt  taste  in  the  mouth.  The 
bowels  are  usually  constipated,  but  sometimes  there  is  marked 
diarrhcea,  and  the  stools  may  contain  mucus  and  blood.  Head- 
ache, pain  in  the  back  and  limbs,  and  vertigo  are  common 
from  the  onset.  The  patient  is  usually  dull  and  depressed, 
and  may  be  very  irritable. 

Of  all  these  symptoms  the  most  common  and  characteristic 
are  the  peculiar  erythematous  eruption  and  some  degree  of  ver- 
tigo. It  is  probable  that  ail  pellagrins  suffer  from  some 
degree  of  vertigo,  and  this,  combined  with  an  erythematous 
eruption  with  the  distribution  above  described,  is  sufficient  to 
establish  a  diagnosis  of  the  disease,  especially  if  they  show  a 
tendency  to  periodic  exacerbation  in  spring  and  remission  in 
winter. 

The  eruption  maintains  its  erythematous  type  for  some 
weeks  after  its  appearance  and  then  fades,  leaving  the  skin 
rough  and  slightly  thickened.  The  affected  parts  are  usually 
found  to  be  stained  a  light  brown  as  the  erythema  disappears- 
With  the  subsidence  of  the  rash,  during  the  first  year  of  the 
attack  at  least,  all  other  symptoms  may  also  subside,  but  it 
is  more  common  to  find  that,  although  the  rash  and  gastro- 
intestinal symptoms  disappear,  the  patient  retains  a  certain 
amount  of  irritability  and  moroseness  beyond  the  normal.  A 
tendency  to  vertigo,  too,  may  persist  after  the  acute  period 
of  the  eruption  has  passed. 

In  some  cases  the  nervous  symptoms  at  the  onset  of  the 
attack  may  be  much  more  severe  than  has  been  indicated. 
The  tongue  may  be  tremulous,  and  the  patient  may  be  troubled 
with  a  burning  sensation  in  the  palms  of  the  hands  and  the 
soles  of  the  feet.  The  vertigo  may  be  very  severe,  the  patient 
exhibiting  a  tendency  to  fall  forwards  or  backwards,  while 
tenderness  in  the  dorsal  region  of  the  spine  and  exaggeration 


Pellagra.  429 

of  tlie  deep  reflexes  are  also  frequently  observed.  Some 
patients  snifer  greatly  from  sleeplessness,  wliile  others  are 
habitually  drowsy.  The  patient  frequently  complains  also 
of  muscular  weakness,  especially  in  the  legs. 

Although  at  the  end  of  a  varying  number  of  weeks  all 
symptoms  usually  disappear  after  the  disease  has  first  made 
its  appearance,  the  symptoms  return  as  a  rule  with  increased 
severity  in  the  following  spring  or  early  summer,  and  after 
persisting  for  some  months  they  again  subside  as  autumn  and 
winter  approach,  only  to  reappear  again  next  spring  or 
summer.  While  the  exacerbations  usually  occur  in  spring 
or  early  summer  and  the  remissions  in  autumn  or  early  winter, 
this  is  not  always  the  case,  and  sometimes  after  a  period  of 
remission  in  late  summer  an  exacerbation  may  occur  in 
autumn.  This  autumn  exacerbation  is  more  common  after 
the  disease  has  been  established  for  some  years  than  early  in 
the  attack. 

As  the  disease  progresses,  the  patient  loses  ver}^  much  in 
general  condition.  He  becomes  thin,  melancholy  and 
irritable.  The  skin  in  the  regions  attacked  by  the  rash  grows 
rougher  and  thicker  with  each  successive  exacerbation,  and 
becomes  gradually  more  and  more  deeply  pigmented. 
Muscular  weakness  and  vertigo  increase,  and  headache  and 
pain  in  the  back  may  become  very  acute,  especially  during 
the  periods  of  exacerbation.  Ultimately,  the  patient  drifts 
into  a  condition  of  melancholia  and  dementia,  and  becomes 
emaciated  and  helpless^  suffering  from  incontinence  of  urine 
and  involuntary  diarrhoea.  Sooner  or  later  most  pellagrins 
drift  either  into  ordinary  asylums  or  into  institutions  specially 
provided  for  the  care  of  these  unfortunate  people  in  the  later 
stages  of  the  disease. 

The  duration  of  pellagra  is  very  variable.  In  some  cases 
the  patient  only  survives  for  two  or  three  years,  but  in  most 
instances  the  disease  is  much  more  chronic,  and  may  persist 
for  ten  or  fifteen  years,  or  even  longer. 

The  prominence  of  the  various  groups  of  symptoms  is 
also  very  variable.  In  some  the  gastro-intestinal  symptoms 
predominate;  in  others  the  cutaneous  symptoms;  in  others, 
again ,    the   nervous ;    but   whatever   group    predominates   the 


430  Chapter  XXVI. 

characteristic  distribution  of  the  rash  is  there  and  the  obstinate 
vertigo.  These  two  symptoms  may  vary  in  degree  but  are 
always  present. 

In  ,'iome  cases  the  mucous  membrane  of  the  gums  is  soft 
and  spongy,  and  bleeds  easily,  and  it  is  this  type  of  case  that 
has  led  to  the  name  of  "  Alpine  scurvy  "  being  given  to  the 
disease. 

The  nervous  symptoms  may  be  at  times  very  violent. 
Epileptiform  seizures  are  not  uncommon  in  the  late  stages  of 
the  illness.  Various  ocular  symptoms  may  be  present,  such 
as  amblyopia  and  diplopia;  ptosis  and  mydriasis  are  also  seen. 

As  the  attack  progresses  the  patient  becomes  pallid,  and 
a  reduction  in  the  number  of  red  cells  and  in  the  amount  of 
hsemoglobin  is  usually  evident.  Sambon,  Terni,  Galasescu 
and  Grigorescu  have  pointed  out  that  a  relative  increase  in 
mononuclear  leukocytes  is  common,  and  this  is  of  value  in 
differentiating  the  eruption  of  pellagra  from  other  erythe- 
matous rashes  with  which  it  might  be  confused.  The  urine 
is  frequently  alkaline,  and  sometimes  ammoniacal,  and  in 
advanced  cases,  albumin  and  tube  casts  are  often  present. 

The  disease  sometimes  assumes  a  very  acute  form,  which 
rapidly  terminates  fatally,  and  such  an  acute  type  may  be 
evident  from  the  onset  of  illness ;  but  an  ordinary  chronic  case 
proceeding,  so  far,  quietly  and  uneventfully  may  one 
year  suddenly  assume  this  acute  and  malignant  form,  and 
the  disease  may  terminate  quickly  in   death. 

An  attack  of  pellagra  which  is  acute  from  the  onset  usually 
runs  a  very  short  course  with  a  duration  of  somewhere  between 
a  fortnight  and  three  months.  The  temperature  is  elevated, 
the  pulse  is  very  rapid,  while  the  patient  suffers  from  severe 
prostration.  The  rapidity  of  the  pulse  and  degree  of  pros- 
tration are  quite  out  of  proportion  to  the  height  of  the  fever. 
The  tongue  is  red  and  deeply  fissured.  Stomatitis  and  pharyn- 
gitis are  common,  and  there  is  evidence  of  acute  catarrh  of 
the  whole  gastro-intestinal  tract.  The  patient  has  difficulty 
in  swallowing,  suffers  from  anorexia  and  nausea,  and  exhibits 
a  profound  degree  of  muscular  weakness.  The  skin  is  dark 
and  livid  in  colour,  and  the  typical  erythema  and  roiigh  skin 
may  be  present.     Petechioe  are  also  frequently  met  with,  and 


Fellagra.  431 

there  is  a  great  tendency  to  tlie  formation  of  bed  sores.  Tlie 
patient  may  suffer  from  extreme  restlessness  and  tremor,  and 
convulsions  or  delirium  and  tetanic  spasms  of  the  muscles  arij 
also  met  with.  Towards  the  end,  mania  or  melancholia  and 
hallucinations  are  quite  common.  Loss  of  control  of  the- 
sphincters  of  bladder  and  rectum  frequently  precedes  death. 

Recovery  from  such  primary  acute  attacks  is  rare.  If 
recovery  does  take  place  it  is  only  temporary,  and  a  fatal 
termination  is  the  rule.  When  such  an  attack  occurs  in  the- 
course  of  a  chronic  pellagra,  it  is  invariably  fatal. 

In  a  chronic  pellagra  which  runs  its  course  without  any 
definite  acute  attack,  death  occurs  from  gradually  increasing 
prostration  and  cachexia,  and  is  usually  preceded  by  a 
condition  of  muscular  and  mental  weakness  so  great  that  the 
patient  lies  helpless  and  practically  unaware  of  his- 
surroundings,  and  dies  ultimately  of  sheer  asthenia. 

In  young  people  a  type  of  pellagra  is  sometimes  met  with 
in  which  the  symptoms  are  confined  to  a  mild  dermatitis  and 
slight  gastro-intestinal  catarrh,  and  in  such  cases  recovery  not 
infrequently  takes  place  at  the  end  of  a  year  or  tw^o,  and  the 
patients  ultimately  grow  up  into  quite  healthy  adults,  and 
do  not  show  for  the  rest  of  their  lives  any  tendency  to  exhibit 
the  symptoms  of  pellagra. 

The  degree  of  fever  in  pellagra  is  very  variable.  It  is 
unusual  to  find,  except  in  acute  fulminating  cases,  that  the 
temperature  is  elevated  at  the  beginning  of  the  attack.  There- 
may  be  perhaps  a  few  days'  fever  now  and  again,  but  pyrexia 
is  not  an  invariable  symptom.  During  the  period  of  recur- 
rence in  successive  years  a  tendency  to  pyrexia  becomes  more 
marked,  but  the  fever  is  irregular  and  is  frequently  quite 
mild.  This  irregular  pyrexia  is  the  general  type  throughout 
the  whole  course  of  an  attack  of  the  usual  more  or  less  chronic 
type. 

Epidemiology. — Until  within  a  very  few  years  ago  pellagra 
was  believed  to  have  the  most  limited  geographical  distribution 
of  any  of  the  acute  specific  infections. 

For  long  it  had  been  known  to  exist  in  Lombardy,  in 
parts  of  Hungary,  Roumania,  France,  Spain,  and  in  Egypt, 


432  CJiapte?'  XXVI. 

but  the  United  States  of  America  and  Great  Britain  were 
supposed  to  be  free  from  the  disease.  Within  recent  years, 
however,,  many  cases  have  been  described  in  the  United  States, 
more  particularly  in  Virginia,  North  and  South  Carolina, 
'Georgia,  Alabama,  Mississippi,  Florida,  Louisiana,  Kentucky, 
Tennessee  and  Texas.  According  to  Roberts,  out  of  forty-nine 
States,  including  the  district  of  Columbia,  pellagra  has 
originated  in  thirty-three,  and  he  states  that  in  his  belief  it 
is  probable  that  there  are  10,000  cases  of  pellagra  in  the  United 
States  at  the  present  day. 

Pellagra  has  also  been  discovered  in  Mexico,  the  West 
Indies,  Cape  Colony,  and  in  certain  parts  of  Northern  Africa 
•other  than  Egypt. 

Great  interest  has  been  aroused  within  the  past  few  years 
by  the  discovery  and  description  by  Sambon  and  others  of 
undoubted  cases  of  pellagra  existing  in  the  British  Isles. 
Several  cases  have  been  discovered  in  the  asylums  of  the 
north-east  of  Scotland,  and  notes  on  some  British  cases  have 
appeared  in  the  "British  Medical  Journal"  and  the  "Lancet," 
in  the  summer  and  autumn  of  1913. 

On  July  5th,  Dr.  Sambon  published  in  the  "  British 
Medical  Journal "  an  interesting  history  of  the  disease  in 
England,  and  gave  full  notes  of  several  cases.  It  was  through 
the  confirmation  by  Dr.  Sambon  of  Dr.  Box's  provisional 
diagnosis  that  an  interesting  family  series  was  discovered. 
One  case  died  in  St.  Thomas'  Hospital ;  an  elder  brother,  who 
seems  to  have  suffered  from  similar  symptoms,  had  died 
previously  in  January,  1911 ;  and  a  third  child  is  presently 
living  at  Slough. 

At  the  request  of  Dr.  Charles  W.  Kay,  of  Lymington, 
Dr.  Sambon  visited  that  district  and  was  able  to  confirm 
Dr.  Kay's  diagnosis  of  pellagra  in  a  patient  living  in  the 
neighbourhood  of  Lymington,  while  Dr.  Hammond  published 
in  the  same  number  of  the  "  British  Medical  Journal "  some 
interesting  notes  of  a  case  who  had  died  in  the  Isle  of 
Wight,  and  who  had  apparently  contracted  the  infection  in 
Scotland.  Through  the  courtesy  of  Dr.  Sambon,  the  writer 
was  able  to  study  the  cases  at  Lymington  and  Slough. 


Pellagra.  435 

In  the  "British  Medical  Journal,"  on  July  lOtli,  Dr. 
Sambon  published  notes  of  three  other  cases  occurring  in 
Shropshire,  Cardiganshire,  and  in  the  County  Asylum  at 
Napsbury,  and  on  August  9th  Dr.  Sambon  made  references 
in  the  "  British  Medical  Journal  "  to  a  case  in  the  Prestwich 
County  Asylum,  and  three  more  cases  at  Napsbury.  Again, 
in  the  "  British  Medical  Journal,"  on  Septeimber  2Tth,  Drs. 
Reid  and  Calwell  publislied  the  notes  on  a  supposed  case- 
of  pellagra  near  Belfast,  and  Dr.  L.  E,.  Lempriere  described 
a  case  which  he  had  discovered  in  Llanidloes,  Glamorgan- 
shire, which  seemed  to  be  a  typical  case  of  pellagra. 

Several  articles  also  appeared  in  the  ''  Lancet,"  notably 
an  excellent  article  by  Dr.  Gurth  S.  Blandy,  of  Kapsbury 
County  Asylum,  in  which  he  mentioned  the  two  cases  at 
Prestwich  under  the  care  of  Dr.  J.  S.  Stephenson,  and  also- 
nine  cases  at  Napsbury.  He  also  stated  in  this  paper  that 
several  doubtful  cases  were  under  observation  at  Napsbury, 
and  he  had  seen  a  case  which  looked  like  a  mild  case  of 
pellagra  at  Hill  End  Asylum.  It  is  interesting  to  note  that 
all  the  cases  at  Napsbury  except  one  were  women,  and  all 
were  in  early  middle  age.  In  the  same  number  of  the 
"Lancet"  Dr.  J.  W.  E.  Cole  described  a  case  at  Bethnall 
House  Asylum.  On  October  18th,  Dr.  Emma  M.  Johnstone, 
of  Hollo  way  Sanatorium,  Virginia  Water,  contributed  to  the 
"  Lancet "  notes  on  three  probable  cases  of  pellagra,  one  of 
which  had  been  under  observation  in  1911  and  two  in  1912. 

While  all  these  papers  were  written  in  the  belief  that 
the  cases  observed  were  definitely  pellagra,  and  the  first  case 
at  Napsbury,  which  through  the  courtesy  of  Drs.  Sambon  and 
Blandy  the  writer  was  permitted  to  see,  appeared  undoubtedly 
to  be  suffering  from  an  acute  specific  disease,  Dr.  W.  Eees 
Thomas  contributed  a  note  to  the  "Lancet,"  on  September 
13th,  suggesting  that  the  cases  described  might  possibly  be 
cases  of  drug  intoxication,  basing  his  suggestion  on  the  fact 
that  in  Italy  only  some  four  per  cent,  of  pellagrins  were  to 
be  found  in  asylums.  The  cases  at  Slough  and  Lymington, 
and  the  first  case  at  Napsbury,  all  of  which  the  writer  has 
seen,  were  certainly  not  cases  of  drug  intoxication,  and,  while 


434  Chapter  XXVI. 

it  may  be  necessary  occasionally  to  distinguish  between  true 
pellagra  and  a  drug  eruption,  it  does  not  seem  likely  that 
any  of  the  cases  described  in  1913  were  drug  intoxications, 
whatever  they  may  have  been.  It  is  possible  that  many  cases 
of  melancholia  and  dementia  which  are  at  present  inmates 
of  our  asylums  may  be  pellagrins  in  the  late  stages  of  the 
disease. 

Pellagra  attacks  both  sexes,  but  under  equal  conditions 
women  seem  to  be  more  readily  infected  than  men.  It  attacks 
people  of  all  ages,  from  infants  to  those  who  have  passed  the 
three  score  years  and  ten.  It  is,  however,  more  common 
among  adults  in  the  prime  of  life  than  among  those  at  the 
extremes  of  age. 

Etiology. — Until  within  very  recent  years  pellagra  has 
been  generally  supposed  to  be  connected  in  some  way  or 
another  with  the  eating  of  maize,  and  just  as  in  the  case 
■  of  rice  and  beriberi,  nitrogen  starvation  or  some  infection 
conveyed  by  the  grain  has  been  thought  to  be  the  cause  of 
the  disease,  and  the  fact  that  pellagra  occurred  so  largely  in 
maize  eating  districts  has  given  a  certain  colour  to  this  belief. 
In  Northern  Italy,  Roumania  and  Spain,  where  pellagra  has 
been  known  to  exist  for  so  long,  the  peasants  eat  maize 
preparations  to  the  exclusion  of  other  cereals,  and  a  somewhat 
'Cursory  survey  of  these  maize  eating  districts  w^ould  seem  to 
show  that  pellagra  appeared  there  with  fairly  uniform 
■distribution.  So  firmly  had  this  idea  taken  hold  of  those 
who  studied  pellagra  that  the  Governments  of  Roumania  and 
Italy  instituted  special  precautions  against  the  possibility  of 
people  of  these  districts  eating  contaminated  or  unsound 
maize ;  special  drying  apparatus  and  Government  bake-houses 
were  built,  and  it  is  said  that  since  the  introduction  of 
these  precautions  pellagra  has  decreased,  except,  curiously 
enough,  in  the  district  of  Perugia  in  Italj^,  where  the  disease 
is  on  the  increase.  In  association  with  these  precautions 
taken  against  the  eating  of  unsound  maize,  the  Governments 
of  Italy  and  Roumania  have  also  instituted  jiellagrosari,  or 
places  for  the  treatment  of  pellagrins,  and  have  also  paid 
•considerable  attention  to  the  better  hygienic  surroundings  of 


Pellagra.  435 

persons  in  these  districts;  liowevei',  it  must  be  remembered  that 
all  over  Northern  Italy  the  last  ten  years  have  be^n  a  period  of 
great  industrial  and  agricultural  progress,  so  that  it  is  difhcult 
to  say  how  far  the  improved  condition  of  the  maize  or  the 
improved  general  hygiene  of  tlie  people  has  been  responsible 
for  the  decrease  in  pellagra  which  is  said  to  have  occurred  in 
these  regions.  The  decrease  does  not  seem  likely,  on  the  face 
>of  it,  to  have  resulted  from  the  supervision  of  maize  alone, 
particularly  as  in  the  district  of  Perugia  no  decrease  has  taken 
place.  Moreover,  even  in  Italy,  in  certain  places  in  which 
maize  is  eaten  freely  no  pellagra  is  found,  as  in  Venice  and  all 
urban  districts,  where  pellagra  does  not  originate,  although  it 
may  be  rife  in  the  immediate  vicinity  of  the  cities.  Another 
interesting  fact  is  that  in  Northern  Italy  many  people  have 
been  known  to  sufler  from  pellagra  who  have  never  eaten  maize 
or  any  of  its  derivatives. 

Some  two  years  ago  Sambon  published  a  paper  in  the 
Journal  of  Tropical  Medicine,  in  which  he  combated  the  idea 
that  pellagra  is  due  to  the  eating  of  unsound  maize,  and  put 
forward  the  theory  that  it  was  due  to  some  infection  by  a 
specific  organism  not  introduced  in^o  the  body  by  food,  and 
supported  his  theory  by  many  interesting  observations. 

Sambon  points  out  that  the  comparison  of  two  islands  off 
Venice  enables  one  to  draw  interesting  conclusions  with  regard 
to  the  etiology  of  pellagra.  The  two  islands  are  Murano  and 
Burano.  The  island  of  Murano  has  been  famous  for  centuries 
for  the  manufacture  of  glass.  All  the  male  inhabitants  are 
glass-makers  and  glass-blowers,  and,  while  they  have  exten- 
sive communication  with  Venice,  have  very  little  traffic  with 
the  mainland.  The  men  in  Burano  are  fishermen,  and  ply 
their  trade  along  the  shores  of  the  mainland.  The  women 
in  both  islands  are  lace-makers,  and  scarcely  ever  leave  home. 
An  exception  to  this  statement  is  that  when  Sambon  visited 
the  islands  there  were  two  women  on  the  island  of  Burano 
who  were  field  workers,  and  did  their  work  on  the  mainland. 
On  the  island  of  Murano,  Sambon  found  no  pellagra,  either 
among  men,  women  or  children.  On  the  island  of  Burano 
all  the  men  practically  were  pellagrins,  while  none  of  the 
children  were  pellagrous,  and  only  the  two  women  who  worked 


436  Chapter  XXVI. 

ou  the  mainland.  All  eat  polenta.  There  was  no  particular 
reason  to  believe  that  the  polenta  in  Murano  was  made  from 
better  maize  than  the  j)olenta  in  Biirano,  and  in  any  case 
the  distribution  of  the  disease  in  the  island  of  Burano  was 
so  unusual  in  the  fact  tliat  so  many  men  and  so  few  women 
were  attacked,  that  it  seemed  likely  that  the  men  were  pella- 
grous because  they  liad  been  exposed  to  an  infection  to  wbich 
the  women  had  not  been  exposed,  seeing  that  if  both  sexes 
have  an  equal  chance  of  taking  tlie  disease  women  suffer  more 
frequently  than  men. 

Erom  tlie  study  of  the  disease  in  these  and  other  districts 
Sambon  came  to  tlie  conclusion  that  it  was  due  to  a  parasitic 
infection  conveyed,  not  by  food,  but  possibly  through  the 
mediation  of  some  biting  insect.  In  his  further  studies  of 
the  geographical  distribution  of  the  disease  Sambon  found 
that  pellagra  was  prevalent  in  those  districts  which  were  near 
rather  rapidly  moving  streams,  in  districts  which  were  not 
marsh  land,  and  which  were,  in  short,  very  different  in 
character  from  those  places  in  which  malaria  was  rife.  In 
looking  for  biting  insects  which  might  convey  the  infection 
vSambon  naturally  set  out  to  find  what  biting  insects  were 
peculiarly  common  in  siich  districts,  and  he  found  that  the 
insects  which  were  most  common  were  certain  species  of  the 
Simuliidce  or  so-called  "  sand-flies,"  the  larval  forms  of  which 
inhabit  rather  rapid  streams.  The  flies  are  found  in  large 
numbers  on  the  stones  and  the  water-plants  in  such  streams. 

Pellagra  is  a  disease  of  the  country  and  not  of  towns, 
and  this  is  interesting  considering  the  habits  of  the  Siinuliidce, 
which  are  strictly  not  domestic. 

The  discovery  of  cases  in  England  is  at  the  present 
time  a  matter  of  extreme  interest,  and  it  is  difficult  to  under- 
stand how  anyone  can  now  hold  firmly  to  the  Zeist  theory 
with  regard  to  the  causation  of  the  disease.  The  complete 
Zeist  holds  that  pellagra  is  always  drie  to  an  intoxication  by 
maize,  and  that  if  a  disease  resembling  pellagra  occurs  in 
people  who  do  not  eat  maize  it  is  therefore  not  pellagra.  The 
cases  in  England,  none  of  whom  ate  maize  habitually,  and 
the  condition  of  things  already  mentioned  as  obtaining  in  the 


Pellagra.  437 

islands  of  Muraiio  and  Burano,  go  far  to  shake  one's  belief  in 
any  Zeist  theory. 

In  all  the  districts  in  wliicli  English  cases  have  appeared, 
and  where  investigation  has  been  inade,  SiviuliidoEi  are  found 
in  great  numbers,  and  while  there  is  at  the  present  moment 
no  proof  that  the  Simuliidce  are  the  carriers  of  the  infection 
of  pellagra,  it  would  seem  likely  that  all  further  investiga- 
tions of  this  disease  will  go  to  prove  Sambon's  theory  that  the 
disease  is  insect-borne  rather  than  to  confirm  the  Zeists  in  the 
position  which  they  have  taken  up.  The  Report  of  the  Com- 
mission in  the  United  States  of  America,  in  whose  delibera- 
tions and  investigations  Sambon  has  taken  an  interested  and 
active  part,  and  the  results  of  Sambon's  own  investigations  in 
the  West  Indies  during  the  autumn  of  1913,  will  be  awaited 
with  the  greatest  interest,  and  as  the  summer  of  1914 
develops  it  seems  more  than  likely  that  a  sufficient  number 
of  cases  will  be  found  in  England  to  give  us  material  for 
interesting  and  profitable  research. 

Sambon's  theory  is  that  pellagra  is  due  to  infection  by 
some  protozoal  parasite  conveyed  to  the  human  being 
by  the  bite  of  certain  of  the  Simuliidce,  or  some 
similar  insect,  just  as  the  parasite  of  malaria  is 
conveyed  to  the  human  being  by  mosquitoes,  and 
his  theory  is  finding  at  the  present  day  wider  and  wider 
acceptance  in  Italy,  and  has  been  most  favourably  received 
throughout  the  United  States  of  America.  It  is  true  that  at 
the  present  moment  the  identity  of  the  infecting  protozoal 
organism  has  not  yet  been  thoroughly  established,  that  forms 
at  all  suggestive  of  such  a  parasite  have  not  been  discovered 
in  the  SimuliuTri,  and  that  experimentally  the  disease  lias  never 
been  conveyed  by  the  Siviulium  to  any  animal ;  but  in  view 
of  Sambon's  careful  study  of  the  geographical  distribution  of 
the  disease  and  of  the  interesting  facts  which  he  has  brought 
forward  to  show  that  so  many  polenta  eating  districts  are  free 
of  the  disease,  and  that  so  many  districts  in  which  no  polenta 
is  eaten  are  pellagrous,  his  belief  seems  to  be  worthy  of  the 
most  careful  consideration,  and  is  suggestive  at  least  of  a  much 
more  probable  causation  of  pellagra  than  maize,  contaminated 


438  Chapter  XXVI. 

or  uucontaminated.  The  fact  that  even  a  few  cases 
liave  been  discovered  in  the  United  Kingdom  in  districts 
where  no  maize  is  eaten  is  enough  to  shake  reasonable  belief 
in  the, idea  that  the  disease  is  conveyed  in  any  way  by  the 
eating  of  maize,  and,  seeing  that  pellagra  is  definitely  on  the 
increase  in  the  United  States,  and  is  knocking  at  our  own 
doors,  a  careful  study  of  its  etiology  along  the  lines  which 
Sambon  indicates  should  be  the  serious  objective  of 
epidemiologists  in  this  country. 

Treatment. — The  treatment  of  pellagra  has  been  so  far  verj- 
unsatisfactory.  In  a  certain  number  of  cases,  perhaps  in  a 
large  number  of  cases,  the  disease  is  capable  of  arrest  if  the 
patient  is  removed  in  the  early  stages  from  a  pellagrous 
district  to  a  place  where  the  disease  is  unknown,  but  in 
removing  a  patient  to  a  new  district  care  sliould  be  taken,  in 
view  of  the  possibility  of  its  being  spread  by  the  Simulium, 
that  such  a  district  should  not  be  one  in  which  the  SimuUuTn 
is  found,  both  for  the  patient's  sake  and  for  the  sake  of  the 
community. 

It  is  possible  that  the  hypodermic  injection  of  certain 
of  the  newer  preparations  of  arsenic,  such  as  salvarsan, 
neosalvarsan,  atoxyl,  or  the  cacodylate  of  soda,  may  be  of 
value  in  the  treatment  of  the  disease,  especially  in  its  earlier 
stages.  A  belief  that  the  disease  is  due  to  a  form  of  protozoal 
infection  would  render  such  treatment  quite  reasonable. 


(   439  ) 


Appendix. 

THE    SERUM   TREATMENT    OF 
TUBERCULOSIS. 


In  the  chapter  on  Pulmonary  Tuberculosis  the  writer 
stated  that  so  far  the  serum  treatment  of  tuberculosis  had  met 
with  little  success.  During  the  past  year,  however,  the  treat- 
ment of  ambulant  cases  of  pulmonary  phthisis  with  a  new 
serum  has  been  undertaken  by  three  members  of  the  staff  of 
Margaret  Street  Hospital  for  Consumption  (McClure,  Bar- 
croft  and  Thomas).  The  serum  used  is  the  invention  of  a 
German  physician,  and  is  called  "  Contra-toxin  No.  4  (Melin- 
arto)."  Dr.  Mehnarto,  in  a  letter  to  the  "Lancet"  on  21st 
June,  1913,  states  that  the  composition  of  the  serum  is  a 
mixture  of  coagulant  and  hsemolytic  snake  serum  and  sheep's 
blood,  the  resulting  serum  having  as  its  objective  the  convey- 
ing of  the  natural  immunity  of  the  sheep  to  the  human  being, 
and  also  a  certain  bactericidal  effect  produced  probably  by  the 
snake  serum. 

Sixty-seven  cases  have  been  sufficiently  long  under  treat- 
ment to  warrant  certain  conclusions  being  drawn.  It  is 
evident  that  the  serum  has  no  disagreeable  effects  on  the 
human  being;  no  true  local  or  focal  reactions  have  been 
observed,  and  any  general  reaction  as  expressed  by  rise  in 
temperature  has  been  so  slight  as  to  warrant  but  little  atten- 
tion. No  serum  disease  has  been  observed,  and  even  in  those 
cases  where  the  injections  were  given  during  the  danger  period 
no  indications  of  anaphylaxis  have  appeared. 

The  series  of  cases  treated  at  Margaret  Street  Hospital 
was    made    up    of    all    classes    and    conditions    of   pulmonary 

GG   2 


440  Aijpejulix. 

phthisis,  some  of  whom  had  been  failures  under  tuberculin 
treatment,  while  certain  others  had  broken  down  after  coining 
home  from  a  sanatorium.  Some  of  the  cases  were  in  a  very 
advanced  stage  of  the  disease;  about  a  sixth  of  the  number 
showed  definite  signs  of  cavitation.  Both  febrile  and  afebrile 
eases  were  treated,  and  haemorrhages  were  not  considered  as 
contra-indications  to  treatment  by  Contra-toxin   No.  4. 

After  some  six  months'  trial  of  the  serum,  we  have  con- 
sidered ten  cases  as  "arrested."  These  were  all  cases  who 
were  in  a  comparatively  early  stage  of  the  disease  when  treat- 
ment was  begun.  Most  of  the  others  have  shown  distinct 
signs  of  improvement,  both  in  general  condition  and  physical 
signs,  and  even  some  advanced  cases  have  shown  such 
improvement  as  to  warrant  one  thinking  that  an  ultimate 
"arrest"  may  be  possible.  vSome  of  the  advanced  cases  were 
in  such  a  condition  of  general  enfeeblemeut  and  suffered  from 
such  an  active  and  wide-spread  lesion  that  from  the  beginning- 
no  hope  was  entertained  of  anything  like  "arrest."  Certain 
of  these  cases  have  been  influenced  but  little  by  the  treatment, 
a  fact  which  has  caused  us  no  surprise. 

The  results  all  over  have  led  us  to  the  conclusion  that  the 
serum  is  worthy  of  careful  and  prolonged  trial,  and  it  seems 
likely  that  in  the  majority  of  cases  improvement  will  result 
from  its  use.  It  is  indeed  interesting  to  see  how  in  many 
cases,  in  spite  of  home  conditions  of  the  most  adverse  kind, 
very  marked  improvement  has  taken  place  in  a  comparatively 
short  time,  even  in  cases  who  when  first  seen  were  in  a  very 
unsatisfactory  condition  both  with  regard  to  extent  of  lesion 
and  deterioration  in  general  health. 

Patients  of  all  ages  were  included  in  the  series,  the  youngest 
being  ten,  and  the  oldest  sixty-five  years  of  age.  Out  of  the 
sixty-seven  cases  three  died,  one  from  a  profuse  haemorrhage 
before  treatment  was  properly  begun;  another,  who  was  a 
highly  febrile  rapidly  advancing  case,  from  asthenia,  in  spite 
of  carefully  regulated  and  continued  treatment  and  rest  in 
bed;  the  third,  a  case  of  long  standing  who  had  had  several 
severe  relapses  before  serum-treatment  was  begun,  died 
suddenly  after  suffering  from  severe  dyspnoea  for  some  hours. 


The  iSerum  Treatment  of  Tuberculosis.  441 

The  serum  is  siinph;  cjI'  adraiiiistijiiioii.  li  li;is  IxMin  our 
practice  in  cases  who  were  afebrile  at  the  coDiiiicncejnent 
of  treatment,  or  who  showed  only  a  moderate  amount  of  daily 
variation  in  temperature,  to  beg;in  the  treatment  by  an  injec- 
tion of  5  c.c.  of  tlie  serum,  giving  four  days  later  an  injection 
of  10  c.c,  and  continuing-  doses  of  10  c.c.  twice  a  week 
until  symptoms  appeared  which  indicated  that  it  was  wise  to 
lengthen  the  period  between  the  doses.  The  indications  for 
lengthening  the  period  between  the  doses  seem  to  l)e  of  two 
kinds.  It  has  been  found  that  after  a  varying  period  of  treat- 
ment by  10  c.c.  twice  in  the  week  many  cases  begin  to 
exhibit  a  slight  daily  rise  in  temperature,  and  at  the  same 
time  complain  of  lassitude  and  perhaps  a  little  headache. 
These  symptoms  we  have  taken  as  indicating  either  that  the 
patient  is  sufl'ering  from  an  excessive  quantity  of  the  serum 
in  the  system,  or  that  the  interaction  of  the  serum  and  the 
tubercle  bacilli  has  resulted  in  the  freeing  of  an  amount  of 
toxin  in  the  patient's  tissues  too  great  for  his  eliminative 
capacity.  This  period  of  slight  fever  and  malaise  we  have 
called,  in  the  meantime,  "the  period  of  saturation."  After 
this  stage  has  been  reached  we  have  found  it  wise  to  lengthen 
the  intervals  between  the  doses  and  even  to  reduce  the  doses 
themselves,  and  we  have  noticed  that  after  the  intervals 
between  doses  have  been  increased,  with  or  without  decrease 
in  the  actual  quantity  of  the  dose,  fever,  malaise  and  head- 
ache have  disappeared,  and  the  progress  of  the  case  thereafter 
has  been  even  more  favourable  than  before  the  occurrence 
of  "saturation."  In  those  cases,  too,  who  have  shown  very 
marked  improvement  both  in  general  health  and  in  physical 
signs,  whose  condition,  in  other  words,  has  reached  such  a 
stage  as  to  warrant  a  hope  that  "arrest"  will  occur,  we  have 
lengthened  the  interval  between  the  doses  and  reduced  the 
quantity  of  each  dose. 

In  cases  which  were  definitely  febrile  at  the  commence- 
ment of  treatment  we  did  not  begin  with  the  full  iuitial  dose 
of  5  c.c,  but  reduced  it  to  2.5  c.c  to  commence  with, 
and  continued  with  doses  of  5  c.c,  given  twice  or  perhaps 
only  once  a  week.  As  fever  disappeared  it  seemed  best  to 
increase  the  dose  to  10  c.c,   and  give  it  once  a  week  until 


442  Appendix. 

either  symptoms  of  saturation  appeared  or  until  the  improve- 
ment of  the  patient  was  such  as  to  warrant  a  reduction  of 
the  dose  or  a  lengthening  of  the  interval  between  the  doses. 
In  children  below  the  age  of,  say,  fourteen  years  it  has  been 
found  advisable  to  begin  with  a  dose  of  1.5  c.c.  and  continue 
with  a  dose  of  3  c.c.  once  or  twice  a  week,  according  to  the 
condition  of  the  patient. 

The  injections  are  best  given  between  the  shoulders,  due 
aseptic  precautions  being  observed,  and  no  inflammatory 
condition  has  been  noted  in  the  large  number  of  injections 
which  have  been  given.  A  certain  amount  of  pain  and  stiff- 
ness in  the  back  is  usual  after  the  first  few  doses ;  this  may 
last  for  two  or  three  days  at  the  commencement  of  treatment, 
but  as  more  injections  are  given  all  that  the  patient  com- 
plains of  is  a  little  stiffness,  and  perhaps  slight  pain  of  a 
few  hours'   duration  on  the  evening  following  the  injection. 

The  effect  on  the  sputum  and  cough  is  interesting.  The 
sputum  is  as  a  rule  definitely  increased  after  a  few  days,  and 
at  the  same  time  it  becomes  distinctly  more  bronchial  in 
character.  At  this  period  cough  is  also  increased,  but  is  not 
usually  A^olent  or  distressing.  The  sputum  then  gradually 
decreases  in  amount,  and  as  the  amount  of  sputum  lessens  it 
is  common  to  find  that  the  patient  suffers  from  a  rather  dry, 
irritating  cough,  which  may  disturb  his  sleep.  This  irritat- 
ing cough,  however,  is  easily  subdued  by  giving  some  linctus 
of  heroin  at  night,  and  by  getting  the  patient  to  spray  his 
throat  well  with  menthol  two  or  three  times  a  day,  and  to 
use  a  menthol  ointment  for  the  nose  night  and  morning. 

Dr.  White  Robertson,  who  has  acted  as  bacteriologist 
during  the  treatment  of  the  series  of  cases  at  Margaret  Street 
Hospital,  conducted  a  careful  bacteriological  examination  of 
the  sputum,  and  has  also  estimated  the  leukocytes  in  the 
blood,  classifying  them  according  to  Arneth's  method.  As 
improvement  takes  place,  the  first  thing  that  has  been  noticed 
in  the  sputum  is  that  phagocytosis  becomes  active,  so  that 
few  free  bacilli  are  seen  in  the  field,  the  others  being  con- 
tained in  phagocytic  cells.  At  the  same  time  the  bacilli 
have  been  observed  to  lose  their  acid-fast  character,  and  to 
show     a  tendency    to  granulation     and     degeneration.       The 


The  Serum  Treatvient  of  Tuberculosis.  443 

counting  of  the  leukocytes  after  Arnetli's  method  lias  in 
Dr.  Eobertson's  hands  proved  of  great  interest  in  the 
observation  of  these  cases.  As  a  general  rule  improvement 
in  the  leukocyte  count  has  been  yari  yassu  with  iniprovement 
in  the  clinical  manifestations.  In  a  few  cases  improvement 
in  the  leukocyte  count  came  before  any  improvement  in 
physical  signs  or  general  condition  had  taken  place,  and  one 
was  able  to  take  a  hopeful  view  of  the  case,  although  at  the 
moment  the  physical  signs  did  not  warrant  this  attitude.  In 
other  cases  a  rapid  improvement  in  physical  signs  was  associ- 
ated with  no  improvement,  or  perhaps  even  a  deterioration, 
in  Arnetli's  count,  and  this  was  frequently  the  case  when  the 
patients  had  quite  definitely  reached  the  period  of  "satura- 
tion." The  probable  explanation  of  this  fact  is  that  the 
patient  was  suffering  from  an  increased  toxaemia,  due  to  a 
rapid  and  extensive  destruction  of  tubercle  bacilli  and  absorp- 
tion of  tuberculous  tissue.  Regulation  of  the  dose  in  all 
such  cases  resulted  in  rapid  improvement  in  the  leukocyte 
count. 

The  observation  of  the  opsonic  index  in  certain  of  the 
patients  under  treatment  gave  some  interesting  results.  The 
opsonic  index  rose  rapidly  to  above  normal,  a  rise  of  from  .8 
to  2.2  being  noted  in  one  case  in  a  fortnight,  and  after 
the  initial  rise  to  very  much  above  normal  the  index  fell  to 
slightly  above  normal,  at  which  level  it  was  maintained. 
The  doses  in  the  cases  in  which  the  opsonic  index  was 
estimated  were  given  only  once  a  week,  and  the  blood  was 
always  taken  immediately  before  the  dose. 

The  simplicity  of  its  administration  and  the  lack  of  any 
focal  reaction  would  seem,  from  the  observations  already 
made,  to  give  Contra-toxin  a  certain  advantage  over  tuber- 
culin, but,  as  in  the  case  of  all  other  forms  of  treatment 
used  for  pulmonary  tuberculosis,  it  should  not  be  relied  on 
entirely,  but  other  conditions  must  be  taken  into  considera- 
tion. The  care  of  the  teeth,  the  rest  of  febrile  cases, 
improvement  in  home  surroundings,  and  I'easonable  feeding, 
are  just  as  necessary  where  Contra-toxin  is  given  as  where 
any  other  form  of  treatment  is  employed. 


INDEX. 


A. 

Aberrant  types  of  diplithoria,  54. 
Abortion  in  relapsing  fever,  101. 

in  smallpox,  293. 
Abortive  type 

of  cerebro-spinal  meningitis,  129. 
of  smallpox,   304. 
Abscess    in    antrum    of    Highmore    in 
influenza,  160. 
in  mastoid  in  scarlet  fever, 

226. 
in  enteric  fever,  21. 
in  typhus,  332. 
in  yellow  fever,  383. 
Achalme's  bacillus,  337. 
Actual  cautery  in  anthrax,  141. 
in  glanders,  151. 
Acute  type  of  cerebro-spinal  mening- 
itis,  127. 
of  glanders,  147. 
of  pellagra,  430. 
Adenitis  in  measles,  258,  260. 
in  scarlet  fever,  225. 
in  smallpox,  293. 
Aestivo- autumnal  or  malignant  malaria 

108. 
African  type  of  relapsing  fever,  100. 
"  Ague-cake,"  114. 
Albuminviria  in  chickenpox,  317. 
in  scarlet  fever,  230. 
in  typhus,  331. 
Alcohol,  6. 

in  anthrax,  141. 

in  cholera,  90. 

in  diphtheria,  64,  68. 

in  dysentery,    amoebic,    205  ; 

bacillary,  198. 
in  enteric  fever,  33. 
in  influenza,  163. 
in  malaria,  117. 
in  relapsing  fever,  1 02. 
in  scarlet  fever,  240. 
in  smallpox,  301,  304. 
in  typhus,  338. 
in  whooping  cough,  408. 
in  yellow  fever,  386. 
Algide  form  of  malaria,  109. 
Algide   stage    or   stage    of   collapse    in 
cholera,   85. 


Alkaline  treatment  in  rheumatic  fever- 

371. 
Alkalis  in  yellow  fever,  380. 
Amblyopia  iu  pellagra.  430. 
Ambulatory  cases  of  enteric  fever,  10. 

form  of  plague,  76. 
Amoebic  dysentery.     See  Dysentery. 
Amyloid  degeneration  of  kidney,  spleen 
or  liver  in  pulmonary  tuber- 
culosis, 172. 
Anaemia  after  cholera,   88. 

after  bacillary  dysentery,  196. 
in  Kala  Azar,  210. 
in  malaria,  112. 
in  rheumatic  fever,  363,  373. 
in  pulmonary  tuberculosis, 
186. 
Anaesthesia  of  skin  in  beriberi,  415,  417. 
Anaphylaxis,  61. 

and  Contra-toxin,  No.  4,  439. 
Angina  Liidovici,  227. 
Ankle-drop  in  beriberi,  415,  417. 
AnophelincF,   123. 
Antlirax,   137  to   145. 

Actual  cautery  in,  141. 

Alcohol  in,  141. 

Anti-anthrax  serum  in,   Sclavo's. 

142. 
Bacteriological  diagnosis  of,  140. 
Cerebro-spinal  symptoms,  type  of, 

with  only,  139. 
Charbon,    or    malignant    pustule, 

137. 
Clinical  types  of,  137  to  139. 
Cough  in,  139. 
Cyanosis  in,  139. 
Death  rate  in,  144. 
Delirium  in,  138. 
Diagnosis  of,  140. 
Diarrhoea  m,  139. 
Dyspnoea  in,  139. 
Epidemiology  of,  143. 
Excision  of  piistule  in,  141. 
Headache  in,  138. 
Home  prophylaxis  in,  144. 
Hypnotics  in,  141. 
Incubation  period  of,  137. 
Infection  in,  143. 
Infectivity  of.  144. 
Intestinal.  138. 


446 


Index 


Anthrax — continued. 

Lymph  channels  in,  138. 
Malignant  pustule,  or  charbon  137, 
Public    health    administration    of, 

145. 
Pulmonarv,  139. 
Pulse  in,  139. 

Puncture  of  spleen  in,  140. 
Respiration  in,  139. 
Spleen  in,  138,  139,  140. 
Spread     of     infection     to     kuigs, 

intestine  and  brain,  138. 
Sputum  in,  139. 
Sweating  in,  138. 
Temperatvire  in,  138,  139. 
Treatment  of,  141. 
Vesicle  in,  137,  138. 
Vomiting  in,  139. 
.\nti-anthrax  serum  (Sclavo's),  142. 
Anti-diphtheritic  serum,  50,  60  to  62. 
.-Vnti-meningococcal  sera,  132,  133. 
Antipyretics,  5. 

in  enteric  fever,  31,  32. 
in  influenza,  161. 
in  Kala  Azar,  213. 
in  malaria,  1 20. 
in  rheumatic  fever,  374. 
in  scarlet  fever,  240. 
in  smallpox,  300. 
in  typhus,  337,  338. 
in  yellow  fever,  386. 
Antitoxic  serum  in  plague,  78,  79. 
.\iiti-typhoid  serum,  42. 
Aperients  in  dysentery,  amoebic,  205  ; 

bacillary,   197. 
Arneth's  method  of  classifying  leuko- 
cytes in  blood,  442. 
Arsenic  in  pellagra,  438. 
Arthritis  in  bacillary  dysentery,  196. 
in  glanders,  147. 
in  rheumatic,  in  scarlet  fever, 

228. 
in  suppurative,  in  scarlet  fever 
227. 
Artificial  pnevunothorax  in  pulmonary 

tuberculosis,  184. 
Ascites  in  Kala  Azar,  211. 
Asthenic  type  of  measles,  256. 
Ataxia  in  beriberi,  415. 


Bacillary  dysentery.    See  Dysentery. 
Bacillus   Anthracis,  137,  140. 

Diphtheria',  47. 

Dysenteri(e,  194,  196. 

enteridiiis  sporogenes,  377. 

Influenzcp,  154,  159. 


Bacillus — continued. 

Mallei,  146,  150. 
of  Finckler  and  Prior,  87. 
Paratyphosus,  27. 
Pestis,  72,  77. 
Pyocyaneus,  194. 
Tuberculosis,  166,  174,     180. 
442. 
Bacteriological  diagnosis 
of  anthrax,  140. 
of  cerebro-spinal  meningitis.  130  to 

132. 
of  cholera,  87. 
of  diphtheria,  55. 
of  dysentery,    amoebic,    202  ; 

bacillary,   196. 
of  enteric  fever,  27  to  29. 
of  glanders,  150. 
of  Kala  Azar,  211. 
of  malaria,  109  to  113. 
of  plagvie,  77. 

of  pulmonary  tuberculosis,  174. 
of  relapsing  fever,  101. 
Bacteriology  of  rheumatic  fever,  377. 
of  scarlet  fever,  237. 
of  whooping  cough,  410. 
of  yellow  fever,  385,  389. 
Balantidium  coli,  194. 
Bed-bug  and  Kala  Azar,  214. 
Beriberi,  414  to  425. 

Anaesthesia  of  skin  in,  415,  417. 
Ankle-drop  in,  415,  417. 
Ataxia  in,  415. 
Bowels  in,  415. 

Cardiac  symptoms  in,  415,  417,  418 
Clinical  tj^pes  of,  414. 
Convalescence  from,  416,  418. 
Death  rate  in,  424. 
Diagnosis  of,  418. 
Diet  in,  420. 
Dry,  414. 

Emaciation  in,  414,  415,  418. 
Epidemiology  of,  420. 
Etiology  of,  421  to  424. 
Gaol  ovitbreaks  of,  424. 
Incubation  period  of,  414. 
Infection  in,  421  to  424. 
Invasion  of,  414,  417. 
CEdema  in,  417. 
Peripheral  neuritis  in,  417. 
Prophylaxis  in,  424. 
Pulse  in,  416. 

Reflexes  in,  deep,  415,  417  ;  super- 
ficial, 415. 
Rice  theory  in,  421  to  424. 
Sequelae  of,  418. 
Temperature  in,  418. 
Tongue  in,  415. 


Index 


44  7 


Beriberi — continued. 
Treatment  of,  419. 
Urine  in,  415,  417. 
Wasting  of  muscles  in,  414. 
Wet,  417. 
Bilharzia  hcematobium,  194,  19G. 
Bilious  remittent  tyjoe  of  malaria,  109. 
Black  or  hgemorrhagic  smallpox,   289. 
Blackwater  fever,  11.5,  116. 
Bleeding  in  relapsing  fever,  102. 

in  scarlet  fever,  245. 
Blindness  after  smallpox,  294. 
Blood  in  enteric  fever,  26,  27,  28. 
inKalaAzar,  210,  221. 
in  malaria,  109  to  113. 
in  pellagra,  430. 
in  pulmonary  tuberculosis, 

442,  443. 
in  relapsing  fever,  101, 
in  rheumatic  fever,  363. 
in  whooping  cough,  403. 
Blood  pressure  in  rheumatic  fever,  363. 

in  yellow  fever,  383. 
Boils  in  typhus,  332. 

in  yellow  fever,  383. 
Breath  in  typhus,  323. 
Bronchial  catarrh  after  malaria,  115. 
in  chickenpox,  317. 
in  diphtheria,  56. 
in  German  measles, 

278. 
in  Kala  Azar,  211. 
in  rheumatic  fever, 

367. 
in  whooping  cough, 
396,  399. 
Bronchiectatic  cavities  after  measles, 

260. 
Bronchitic  type  of  influenza,  155. 
Bronchitis,  capillary,  in  measles,  256. 
chronic,  after  measles,  260. 
in  cholera,  88. 
in  relapsing  fever,  101. 
in  typhus,  329. 
septic,  in  smallpox,  292. 
Broncho-pneumonia 
after  malaria,  115. 
chronic,  after  measles,  260. 
in  chickenpox,  317. 
in  diphtheria,  57. 
in  naeasles,  256. 
in  whooping  cough,  399. 
pyogenic,  in  glanders,  151. 
septic,  m  smallpox,  292. 
Bubo  in  plague,  74. 
Bubonic  plague,  74. 


Bubonic  swellings  of  lymphatic  glands 
in  typhus,  331. 
in  yollow  fever,  383. 


C. 


Cachexia  after  diphtheria,  57. 
Calomel  treatment  of  enteric  fever,  34. 
Cancrum  oris  in  Kala  Azar,  211. 

in  measles,  259. 
Cardiac  changes  after  malaria,   115. 

complications     in     rheumatic 

fever,  362,  363  to  367. 
degeneration  in  influenza,  159. 
dilatation  in  whooping  cough, 

402. 
distress  in  typhus,  330. 
embarrassment  after  measles, 

260. 
failure  in  diphtheria,  51. 
failure  in  influenza,   156. 
failure  in  malaria,   109. 
failure  in    pulmonary    tuber- 
culosis,  172,   186. 
failure  in  relapsing  fever,  100. 
muscle,  acute  granular  disin- 
tegration in  typhu8„ 
330. 
muscle,  permanent    weakness 

after  beriberi,  418. 
symptoms    in    beriberi,    415, 

417,  418. 
weakness  after  diphtheria,  57. 
Catarrh  chronic  nasal  and  post-nasaK 
after  scarlet  fever,  233. 
collateral,       in      .  pulmonary 
tuberculosis,   169. 
Catarrhal  symptoms 

in  cerebro- spinal  meningitis,  126. 
in  enteric  fever,   11,   13. 
in  German  measles,  275. 
in  glanders,  148. 
in  influenza,   155. 
in  measles,  254. 
in  whooping  cough,  395. 
Catarrhal  type  of  influenza,   155. 
Cellulitis  in  glanders,   148,   151. 

in  smallpox,  291. 
Cerebral  symptons  in  influenza,   157. 

in  malaria,  109. 
Cerebro- spinal  fluid   in  cerebro-spinal 
meningitis,   130,   131,   133. 
Cerebro-spinal    meningitis    (epidemic), 
125  to   136. 
Abortive  tj^e  of,   129. 
Acute  type  of,   127. 
Agglutination  test  in,  132. 


448 


IndeA 


Cerebro -spinal  meningitis  (epidemic) — 

continued. 
Anti-meningococcal    sera  in,   132, 

133. 
Bacteriological  diagnosis  of,   130. 
Catarrhal  symptoms  in,   126. 
Cerebro-spinal  fluid  in,    133. 
Cerebro-spinal  fluid  in,    examina- 
tion of,   130,   131. 
Chronic  type  of,   128. 
Clinical  types  of,   126  to   129. 
Complications  of,   129. 
Deafness  in,   128. 
Death  rate  in,   135. 
Delirium  in,   127. 
Diagnosis  of,   129  to   132. 
Emaciation  in,   128. 
Epidemiology  of,   134. 
Facies  of,   127. 
Glasgow    epidemic    of    1906    and 

1907,   125,   126. 
Hsemorrhagic  eruption  in,   125. 
Headache  in,   126. 
Herpetic  eruption  in,   126. 
Hippus  in,   128,   129. 
Home  prophylaxis  in,   135. 
HyperaBsthesia  in,   127. 
Hypnotics  in,   132. 
Incubation  period  of,  125. 
Infection  in,   134. 
Infectivity  of,   135. 
Injection     of     blood-serum     into 

subarachnoid  space  in,   133. 
Invasion  of,   126. 
Kernig's  sign  in,   127. 
Lumbar  puncture  in,   130. 
Mild  type  of,   128. 
Muscular  tremor  in,   128. 
Opisthotonos  in,   127,   128. 
Opsonic  index  in,   132. 
Optic  disc  in,  hyperaemia  of,  128. 
Otitis  media  in,   128. 
Paresis  of  muscles  in,   128. 
Photophobia  in,   127. 
Public  health   administration    of, 

136. 
Piilse  in,   127. 
Pupils  in,   127. 
Rash  in,   125. 
Pveflexes  in,  knee,   127  ;    plantar, 

127. 
Relapses  in,   129. 
Retraction  of  head  in,   127. 
Rigor  in,   126. 
Sequela?  of,   129. 
Squint  in,   128. 
Temperatiu-e  in,   127,   128. 
Treatment  of,   132. 


Cerebro-spinal  meningitis  (epidemic) — 
continued. 
Treatment  of  sequelae  of,  134. 
Vertigo  in,   126. 
Vomiting  in,   126,   128. 
Cerebro-spinal  symptons    in    anthrax, 

139. 
Charbon.     See  Anthrax,   137. 

Chickenpox,  313  to  320. 
Clinical  types  of,  314. 
Complications  of,  317. 
Death  rate  in,  320. 
Diagnosis  of,  317, 
Diet  in,  319. 
Epidemiology  of,  319. 
Gangrenous  type  of,  316. 
Hsemorrhagic  type  of,  316. 
Home  prophylaxis  in,  320. 
Incubation  period  of,  313. 
Infection  in,  319. 
Infectivity  of,  319. 
Invasion  of,  314. 
Public    health   administration    of, 

320. 
Rashin,313,  314,  315,  316. 
Second  attacks  of,  320. 
Sequel*  of,  317. 
Temperature  in,  314,  315. 
Treatment  of,  319. 
Cholera,  84  to  96. 
Alcohol  in,  90. 
Algide  stage  or  stage  of  collapse  of, 

85. 
Bacteriological  diagnosis  of,  87. 
Clinical  types  of,  84  to  87. 
Complications  of,  88. 
Convalescence  from,  88. 
Death  rate  in,  94. 
Delirium  in,  85,  86. 
Diagnosis  of,  87. 
DiarrhcBain,  84,  86,  90,  91. 
Diet  in,  92. 
Epidemiology  of,  92. 
Febrile  reaction  in,  85. 
Headache  in,   84. 
Incubation  period  of,  84. 
Infection  in,  92,  93. 
Infectivity  of,  93. 
Injections,  intravenous,   of  saline 

solutions  in,  89. 
Invasion  of,  84. 
Mild  forms  of,  86. 
Permanganates  in,  90. 
Personal  prophylaxis  in,  94. 
Premonitory  diarrhoea  in,  84. 
Prophylactic  inoculations  against, 

96. 


Index 


449 


(cholera — continued 

Public    healtli    adTiiinistration    of, 
94,  95. 

Pulse  in,  85. 

Quarantiiio  in,  95. 

Hash  in,  84. 

Relapse  in,  87. 

Respiration  in,  85. 

Sequelae  of,  88. 

Stage  of  collapse  in,  85. 

Stools  in,  84,  86. 

Subsultus  tendinum  in,  86. 

Temperature  in,  85,  86. 

Tongue  in,  86. 

Treatment  of,  88  to  92. 

Treatment  of  complications  of,  91. 

Urine  in,  85. 

Vomiting  in,  85,  90. 

Water-borne  epidemics  of,  92,  93. 
Cholera  sicca,  86. 
■'  Cholera-typhoid,"  86. 
Chronic  type  of  cerebro- spinal  mening- 
itis, 128. 
of  glanders,  148. 
of  pellagra,  431. 
phthisis    with    softening,    169. 
Cinch  onism,  117. 
Climatic    treatment    of    {pulmonary 

tuberculosis,  175. 
Climatology  of  rheumatic  fever,  378. 
Cold  stage  in  malaria,  106,  108. 
Colitis  after  cholera,  88. 
Collapse,  stage  of,   or  algide  stage  in 

cholera,  85. 
Collapse  of  lung  after  measles,  260. 

in  whooping  cough,  400 
Collar  neck  in  scarlet  fever,  222,  227. 
Comma  bacillus.   See   Vibrio  cholercB. 
Complications 

of  cerebro-spinal  meningitis,  129. 

of  chickenpox,  317. 

of  cholera,  88. 

of  diphtheria,  56,  57. 

of  dysentery,    amoebic,    201  ; 
bacillary,  195. 

of  enteric  fever,  17  to  23. 

of  German  measles,  277. 

of  glanders,  150. 

of  influenza,  159. 

of  Kala  Azar,  210. 

of  malaria,  113. 

of  measles,  256  to  259. 

of  mumps,  349. 

of  plague,  78. 

of  pulmonary  tuberculosis,  172. 

of  relapsing  fever,  101. 

of  rheumatic  fever,  363. 


Complications — continued. 

of  Hoariot  fovor,  224  to  232. 
of  smallpox,  291. 
of  typhus,  329. 

of  whooping  cougli,  399  to  402. 
of  yellow  fever,  383. 
Conjunctivitis  in  measles,  258. 

in  smallpox,  291. 
Constipation  in  amfiibic  dysentery, 
200,  20.5. 
in  enteric  fever,  1 4. 
in  relapsing  fever,  99. 
in  rheumatic  fever,  374. 
Contra-toxin,  No.  4  (Mehnarto)  in  the 
treatment  of  pulmonary  tuber- 
culosis, 439  to  443. 
Administration  of,  44 1 ,  442. 
Afebrile  cases  treated  with,  441. 
Anaphylaxis  and,  439. 
"  Arrested  "  cases  after  treatment 

with,  440. 
Blood,  examination  of,  442. 
Composition  of,  439. 
Cough  and,  442. 
Dosage  of,  441,  442. 
Febrile  cases  treated  with,  441. 
Opsonic  index  and,  443. 
Reactions,  local,  focal  and  general, 

and,  439. 
"  Saturation  "    during    treatment 

with,  441. 
Serum  disease  and,  439. 
Sputum  and,  442. 
Sputum,  examination  of,  442. 
Convalescence  from  beriberi,  416,  418. 
from  cholera,  88. 
from  dysentery, amcebic, 
200  ;    bacillary,  195 
from  enteric  fever,  15. 
from  infivienza,  155,  156, 

160. 
from  measles,  255. 
from    rheumatic    fever, 

361,373. 
from  smallpox,  288,  289, 

304. 
from  typhus,  325,  332. 
Convulsions  in  pellagra,  431. 

in  whooping-cough,  400. 
Cornea,  opacities  of,  after  measles,  260. 
Corneal  ulcer  in  measles,  258. 

in  smallpox,  291. 
Cough  in  anthrax,  139. 

in  influenza,  155,  156. 
in  measles,  254. 

inpvilmonary  tuberculosis,  168, 
169,  172,  184,  442. 


450 


Index 


Cough  — continued. 

in  whooping    cough,    395,    396, 
397,  398. 
•Crisis,  definition  of,  2. 

in  relapsing  fever,  99. 

in  typhiis,  324. 
Critical  discharges,  3. 

"  Crusting  "  in  smallpox,  288. 

Culture,    differential,    of    B.    Typhosus 
and  B.  Paratyphosus,  28. 
from  blood,  in  anthrax,  150. 
from  blood,  in  enteric  fever,  28. 
from  blood,  in  Kala  Azar,  213. 
from  bubo  in  plague,  77. 
from  cerebro-spinal  fluid  in  cere- 

bro -spinal  meningitis,  131. 
from  stools  in  cholera,  87. 
from  stools  in  bacillary  dj^sentery, 

196. 
from  vesicle  in  anthrax,  140. 
Cupping,   dry,  in  cholera,  91. 
dry,  in  measles,  265. 
wet,  in  scarlet  fever,  245. 
Cystitis  in  enteric  fever,  22. 
in  typhus,  331. 


D. 

Deafness  in  cerebro-spinal    meningitis, 
128,   129. 
in  enteric  fever,  11. 
after  mumps,  351. 
J)eath  rate  in  anthrax,  144. 
in  beriberi,  424. 
in  cerebro-spinal  meningitis 

135. 
in  chickenpox,  320. 
in  cholera,  94. 
in  diphtheria,  69. 
in  dysentery,  amoebic,  206  ; 

bacillary,   198. 
in  enteric  fever,  43. 
in  glanders,  152. 
in  influenza,  164. 
in  Kala  Azar,  215. 
in  measles,  270. 
in  mumps,  356. 
in  plague,  81. 
in  pulmonary  tuberculosis, 

189. 
in  relajDsing  fever,  103. 
in  scarlet  fever,  249. 
in  smallpox,  305. 
in  typhus,  344. 
in  whooping  cough,  411. 
in  yellow  fever,  391. 


Delirium  in  anthrax,  138. 

in  cerebro-spinal  meningitis, 
127. 

in  cholera,  85,  86. 
in  enteric  fever,  13. 
in  influenza,  156,  157. 
in  pellagra,  431. 
in  plague,  73,  75. 
in  relapsing  fever,  98. 
in  rheumatic  fever,  361. 
in  scarlet  fever,  220,  221. 
in  smallpox,  288,  290,  293. 
in  typhus,  323,  324. 
in  yellow  fever,  381. 
Dementia  in  pellagra,  429. 
Deneke's  Vibrio,  87. 
Desquamation  in  German  measles,  277. 
in  measles,  253. 
in  scarlet  fever,  218,  224 
Diagnosis  of  anthrax,  140. 
of  beriberi,  418. 
of  cerebro-spinal  meningitis, 

129  to  132. 
of  chickenpox,  317. 
of  cholera,  87. 
of  diphtheria,  54,  55. 
of  dysentery,   amoebic,   202  ; 

bacillary,  196. 
of  enteric  fever,  25  to  29. 
of  German  measles,  278. 
of  glanders,  149. 
of  influenza,  158. 
of  Kala  Azar,  211. 
of  malaria,  109  to  113. 
of  measles,  261. 
of  mumps,  352. 
of  plague,  76. 
of  pulmonary   tuberculosis, 

173. 
of  relapsing  fever,  100,  101. 
of  rheumatic  fever,  368. 
of  scarlet  fever,  234  to  238. 
of  smallpox,  294  to  299. 
of  typhus,  332  to  337. 
of  whooping  cough,  403. 
of  yellow  fever,  383. 
Diarrhoea  after    bacillary    dysentery, 
196. 
in  amoebic    dysentery,     200, 

202. 
in  anthrax,  139. 
in  cholera,  84,  86,  90,  91. 
in  enteric  fever,  14, 
in  influenza,  156. 
in  Kala  Azar,  210. 
in  malaria,  109. 
in  pellagra,  428. 
in  plague,  75. 


Index 


451 


Diarrhoea — continued. 

in  pulmonary   tuberculosis, 
172,   185. 

in  relapsing  fever,  99,  101. 

in  scarlet  fever,  221,  232. 

in  smallpox,  288. 

in  typhus,  332. 

in  whooping  cough,  401. 
Diet,  6. 

in  beriberi,  420. 

in  chickenpox,  319. 

in  cholera,  92. 

in  dysentery,  amcebic,  205  ; 

bacillary,  198. 
in  enteric  fever,  35. 
in  German  measles,  281. 
in  glanders,  151. 
in  influenza,  163. 
in  Kala  Azar,  213. 
in  malaria,  121. 
in  measles,  269. 
in  mumps,  355. 

in  pulmonary  tuberculosis,  187. 
in  relapsing  fever,  102 
in  rheumatic  fever,  376. 
in  scarlet  fever,  246. 
in  smallpox,  304. 
in  typhus,  342. 
in  whooping  cough,  409. 
in  yellow  fever,  387. 
Digestion  in  Kala  Azar,  210. 
Diphtheria,  47  to  71. 

Aberrant  types  of,  54. 

Alcohol  in,  64,  68. 

Antitoxin  in,  50,  60  to  62. 

Bacteriological  diagnosis  of,  55. 

Cardiac  failure  in,  51. 

Clinical  types  of,  48  to  54. 

Complications  of,  56,  57. 

Death  rate  in,  69. 

Diagnosis  of,  54,  55. 

Diphtheritic  palsies,  58,  59. 

Epidemiology  of,  69. 

Faucial,  48. 

Home  prophylaxis  in,  70. 

Hypnotics  in,  68, 

Incubation  period  of,  47. 

Infection  in,  69. 

Infectivity  of,  69. 

Intubation  in,  66. 

Invasion  of,  47. 

Laryngeal,  52. 

Nasal,  51. 

Public  health  administration  of,  7 1 

Pulse  in,  48,  49,  51. 

Sequelae  of,  57  to  59. 

Temperatxare  in,  48,  49. 

Throat  in,  48,  49. 


Diphtheria — continued. 

Tracheotomy  in,  03,  03  to  00. 

Treatment  of,  59  to  67. 

Treatment   of   complications   of. 
67  to  69. 

Vomiting  in,  57. 
Diplococcus  menim/ilidis  intrucelluluris 
of   Weichsolbaum,    131,    132, 
134. 

rhenmaiiciis,  377. 
Diplopia  in  jiellagra,  430. 
Diuretics  in  relapsing  fever,   102. 

in  scarlet  fever,  246. 
Double  tertian  malaria,  1 07. 
Drains  and  diphtheria,  71. 
Drug  treatment  of  whooping  cough, 

407. 
Dry  beriberi,  414. 
Dysentery,  amoebic,  199  to  207. 

Alcohol  in,  205. 

Aperients  in,  205. 

Bacteriological  diagnosis  of,  202. 

Blood  cormt  in,  201. 

Clinical  types  of,  199,  200. 

Complications  of,  201. 

Constipation  in,  200,  205. 

Convalescence  from,  200. 

Death  rate  in,  206. 

Diagnosis  of,  202. 

Diarrhoea  in,  200. 

Diet  in,  205. 

Enemata  in,  205. 

Epidemiology  of,  206. 

Home  prophylaxis  in,  206. 

Infection  in.  206. 

Infectivity  of,  206. 

Ipecacuanha  in,  203. 

Latent  form  of,  200. 

Leukocytosis  in,  201. 

Public   health    administration    of, 
207. 

Sequelae  of,  202. 

Stools  in,   199,  200,  202. 

Sweats  in,  201. 

Temperature  in,   199. 

Tenesmus  in,   199,  200. 

Treatment  of,  203. 

Treatment  of  complications  of,  204 

Ulceration  of  colon  in,  199. 

Water  supply  in,  207. 
Dysentery,  bacillary,   194  to  207. 

Alcohol   in,    198. 

Aperients  in,  197. 

Bacteriological  diagnosis  of,  190. 

Clinical  types  of,  1 95. 

Complications  of,  195. 

Convalescence  from,  195. 


452 


Index 


D3'sentery,  bacillary—  continued. 

Death  rate,  in  198. 

Diagnosis  of,   19(5. 

Diet  in,  198. 

Enemata  in,   197. 

Epidemiology  of,   198. 

Home  prophylaxis  in,  199. 

Incubation  period  of,  194. 

Infection  in,  198. 

Infectivity  of,  198. 

Intestinal  catarrh  in,  195. 

Public  health  administration  of, 
198. 

Pulse  in,  195. 

Sequelae  of,  196. 

Stools  in,   195. 

Temperature  in,   195. 

Tenesmus  in,   195. 

Tongue  in,   195. 

Treatment  of,   196. 
Dysentery,  form  of,  in  Kala  Azar,  210. 
in  relapsing  fever, 
101. 
Dyspepsia    after    dysentery,    amcebic, 
202  ;   bacillary,  196. 


E. 


Eczema  after  malaria,  115. 

Emaciation  in  beriberi,  414,  415,  418. 
in  cerebro-spinal  mening- 
itis, 128. 
in  Kala  Azar,  209,  210. 
in  pellagra,  429. 
in  pulmonary  tuberculosis, 
170. 
Emetics  in  relapsing  fever,  102. 

Emphysema  after  measles,  260. 

after  whooping  cough, 

402.  _ 
compensatory,  in  whoop- 
ing cough,  400. 
Empyema  in  enteric  fever,  22. 
in  inflvienza,  160. 
in  pulmonary    tuberculosis, 

186. 
of    frontal    sinuses    in    in- 
fluenza, 160. 
Endocarditis  after  whooping  cough,403 
in  bacillary  dysentery, 

196. 
in  enteric  fever,  23. 
in  influenza,  159. 
in  measles,  259. 
in  rheumatic  fever,  364. 
in  scarlet  fever,  227. 


Enteric  fever,  10  to  46. 

Alcohol  in,  33. 

Ambulatory  cases  of,  16. 

Anti -typhoid  serum  in,  42. 

Bacteriological  diagnosis  of.  27  to 
29. 

Blood  in,  27. 

Calomel  treatment  of,  34. 

Catarrhal  symptoms  in,  11,  13. 

Clinical  types  of,  11  to  16. 

Complications  of,  17  to  23. 

Congestion  of  lungs  in,  13. 

Constipation  in,  14. 

Convalescence  from,  15. 

Deafness  in,  11. 

Death  rate  in,  43. 

Delirium  in,  13. 

Diagnosis  of,  25  to  29. 

Diarrhoea  in,   14. 

Diet  in,  35. 

Epidemiology  of,  42. 

Headache  in,  1 1 . 

Home  prophylaxis  in,  44. 

Hypnotics  in,  31. 

Incubation  period  of,  10. 

Infection  in,  42. 

Infectivity  of,  42. 

Invasion  of,  11. 

Milk  epidemics  of,  45. 

Moderate  type  of,  13  to  15. 

Prodromal  rash  in,  12. 

Public  health  administration  of,  45 

Pulse  in,  13,  17. 

Punctvu-e  of  spleen  in,  29. 

Purgatives  in,  33. 

Rash  in,  10. 

Reflexes  in,  knee,   24,   25  ; 
plantar,  25. 

Relapses  in,  29. 

Respiration  in,  13. 

Rigor  in,  14. 

Sequelae  of,  23. 

Severe  types  of,  15,  16. 

Spleen  in,  13,  29. 

Stools  in,  15. 

Temperature  in,  13,  14. 

Tongvie  in,  13. 

Treatment  of,  30. 

Treatment    of    complications    of, 

37  to  41. 
"  Typhoid  spine  "  in,  24,  25. 

Vaccines  in,  41. 
Enteritis   after  cholera,  88. 

in  measles,  259. 
Epidemiology  of  anthrax,  143. 
of  beriberi,  420. 
of  cerebro-spinal 

meningitis,  134. 


Index 


453 


Epidemiology — continued. 

of  chickonpox,  81!). 
of  cholera,  92. 
of  diphtheria,  09. 
,  of  dysentei  V,    amoebic, 

200  ;    hacillary,  198 
of  enteric  fever,  42. 
of  German  measles,  281. 
of  glanders,  151. 
of  influenza,  103. 
of  Kala  Azar,  213. 
of  malaria,  122. 
of  measles,  209. 
of  mixmps,  355. 
of  pellagra,  431. 
of  plague,  79. 
of  pulmonary  tuber- 
culosis, 187. 
of  relapsing  fever,  103. 
of  scarlet  fever,  247. 
of  smallpox,  305. 
of  typhus,  343. 
of  whooping  cough,  410. 
of  yellow  fever,  387. 
Epileptiform  seizures  in  pellagra,  430. 
Epistaxis  after  malaria,  114. 

in  relapsing  fever,  99. 
Erythema  nodosum 

after  malaria,   115. 
in  rheumatic  fever,  308. 
Etiology  of  beriberi,  421  to  424. 
of  pellagra,  434  to  438. 
European  and  Indian  type  of  relapsing 

fever,  98. 
Examination  of    chest    in  pulmonary 

tuberculosis,  175. 
Excavation  in  pulmonary  tuberculosis, 

169. 
Exercise,     graduated,     in     pulmonary 

tuberculosis,  179,  180. 
Eyes  in  measles,  254. 

in  scarlet  fever,  220. 

in  typhus,  324. 

in  yellow  fever,  380,  381. 


F. 


Facies  of  cerebro -spinal  meningitis,  127 

of  measles,  254. 

of  plague,  73. 

of  rheumatic  fever,  359. 

of  scarlet  fever,  220. 

of  smallpox,  289. 

of  typhus,  323,  327. 

of  yellow  fever,  380,  381. 
False  membrane  in  diphtheria,  48. 
"Farcy,"  146, 


Fastigiura,  definition  of,  2. 
Faucial  diphtheria,  48. 
Febrile  reaction  in  cholera,  85. 
Htato,    1 . 

state,    treatment  of,  4  to  9. 
type  of  influenza,  154. 
Fever,  continued,  2. 

intermittent,  2. 
remittent,  2. 
Fibroid  phthisis,    17 J. 
Finsen's  rod  light  treatment  in  small- 
pox, 303. 
Fleas  and  plague,  80. 
Flexner's    serum     in    cerebro-spinal 

meningitis,   133. 
Fulminant  types  of  measles,  255. 
type  of  typhus,  327. 

G. 

Galvanism    after    cerebro-spinal 

meningitis,   134. 
Gangrene  in  amcBbic  dysentery,  202. 
in  cholera,  88. 
in  malaria,  1 1 3. 
in  typhus,  330. 
Gangrenous  type  of  chickenpox,  316. 
Gaol  outbreaks  of  beriberi,  424. 
Gastric  dyspejDsia  in  tuberculosis,  172, 
185. 
symptoms  in  whooping  cough, 

401. 
symptoms  in  yellow  fever,  380, 
381,  382. 
Gastro -intestinal  symptoms  in  pellagra, 
427,  430. 
type  of  influenza,  156. 
German  measles,  274  to  282. 

Catarrhal  symptoms  in,  275. 

Clinical  types  of,  276. 

Complications  of,  277. 

Desquamation  in,  277. 

Diagnosis  of,  278. 

Diet  in,  281. 

Epidemiology  of,  281. 

Glands  in,  276. 

Home  prophylaxis  in,  281. 

Incubation  period  of,  274. 

Infection  in,  281. 

Infectivity  of,  281. 

Invasion  of,  275. 

Public   health   administration   of, 

282. 
Rash  in,  274,  276. 
Second  attacks  of,  281. 
Sequel*  of,  278. 
Temperature  in,  275,  277. 
Treatment  of,  280. 


HH 


454 


Index 


Glanders,  146  to  153. 

Actual  cauterj'-  in,   151. 
Acute,  147. 
Arthritis  in,  147. 
Bacteriological  diagnosis  of,  150. 
Catarrhal  symptoms  m,  148. 
Cellulitis  in,  148,  151. 
Chronic,   148. 
Clinical  types  of,  146. 
Complications  of,  150. 
Death  rate  in,  152. 
Diagnosis  of,  149. 
Diet  in,  151. 
Epidemiology  of,  151. 
Headache  in,  147. 
Home  prophylaxis  of,  152. 
Incubation  period  in,  146. 
Infection  in,  152. 
Infectivity  of,  152. 
Injectioii   of   bxillock's   serum   in, 
151  ;    of  Lugol's  solution  in, 
151. 
Invasion  of,  147,  148. 
Lmigs  in,  148. 
Mallein  in,  150,  151. 
Mild  cases  of,  148. 
Nodules  in,  147. 
Pneumonia,  subacute,  in,  147. 
Public    health    administration   of, 

153. 
Rash  in,  146. 

Rheumatic  symptoms  in,  148. 
Sequelae  of,  151. 

Subperiosteal  abscess  in,  147,  150. 
Temperature  in,  147. 
Treatment  of,  151. 
Glands  in  German  measles,  276. 
in  mumps,  347,  348. 
in  scarlet  fever,  220,  222. 
in  whooping  cough,  403. 
Glasgow    epidemic    of    cerebro -spinal 
meningitis  of  1906  and  1907, 
125     126. 
of  plague  in  1900,  74,  75,  77,  80, 
82,  83. 
Glossitis  in  smallpox,  292. 
Gums  in  pellagra,  430. 

H. 

Hsematemesis  after  malaria,  114. 
,  in  typhus,  332. 

Htematuria  after  malaria,   114. 

in  enteric  fever,  22. 

in  scarlet  fever,  230. 

in  smallpox,  290. 

in  typhus,  331. 
Hsemic  miirmurs  in  Kala  Azar,  210. 


Hsemoglobiiiui'ia  in  blackwater  fever, 

115. 
Hcemoptysis  in  pulmonary  tuberculosis 
170,   172,'  186. 
in  typhus,  330. 
Haemorrhages  in  amoebic  dysentery, 
202. 
in  enteric  fever,  19  to  21 
in  influenza,  160. 
in  Kala  Azar,  210. 
in  malaria,  109,  113,  114 
in  plague,  75. 
in  relapsing  fever,  100. 
in  smallpox,  289,  290. 
in  typhus,  332. 
in  whooping  cough,  401. 
in  yellow  fever,  381. 
Haemorrhagic  eruption    in    cerebro- 
spinal meningitis, 
125. 
infarction     of    Itmg    in 

enteric  fever,  22. 
or  black  smallpox,  289. 
type  of  chickenpox,  316. 
Haffkine's  vaccine  in  plague,  82. 

prophylactic    inoculations 
against  cholera,  96. 
Hallucinations  in  pellagra,  431. 

Headache  in  anthrax,  138. 

in  cerebro -spinal  meningitis, 
126. 

in  cholera,  84. 

in  enteric  fever,  11. 

in  glanders,  147. 

in  influenza,  154,  157. 

in  malaria,   106. 

in  pellagra,  428. 

in  plague,  73. 

in  relapsing  fever,  98, 
•    in  scarlet  fever,  219,  221. 

in  smallpox,  283. 

in  typhus,  322. 

in  yellow  fever,  380. 
Head    retraction    in    cerebro -spinal 

meningitis,   127. 
Heart.     See  Cardiac. 

Hemiplegia  in  smallpox,  293. 
in  typhus,  332. 

Hepatic  abscess  after  amoebic  dysen- 
tery, 201. 

Hepatitis  in  amoebic  dysentery,  201. 
in  yellow  fever,  383. 

Heredity    of    pulmonary    tuberculosis, 
174,   189. 

Hernia  in  whooping  cough,  402. 

Herpes  after  malaria,  114. 


Index 


455 


Herpetic    eruption    in    corobro-spinal 

meningitis,   12G. 
Herpetomenas,  208. 

Hiccough  in  typhus,  324. 

in  yellow  fever,  381. 
Hippua    in    cerebro -spinal    meningitis, 

128,   129. 
Hot  stage  in  malaria,  lOG,  108. 

Hydrocephalus,    chronic,    in    cerebro- 
spinal meningitis,  129. 
Hydropneumothorax    in    pulmonary 

tuberculosis,  186. 
Hydrotherapy  in  cerebro -spinal 

meningitis,   132. 
in  cholera,  91. 
in  diphtheria,  68. 
in  enteric  fever,  31,  32. 
in  influenza,  161. 
in  malaria,  120. 
in  measles,  262. 
in  relapsing  fever,  102. 
inrhevimatic  fever,  371, 

374. 
in  scarlet  fever,  240,  245 

246. 
in  smallpox,  299,  300. 
in  typhus,  338. 
in  yellow  fever,  385,  386 
Hypersesthesia  in  cerebro -spinal 

meningitis,   127. 
Hyperpyrexia,  2, 

Hypnotics,  8. 

in  anthrax,  141. 

in  cerebro-spinal  meningitis,  132. 

in  diphtheria,  68. 

in  enteric  fever,  31. 

in  influenza,  162, 

in  plague,  78. 

in  relapsing  fever,  102. 

in  rheiimatic  fever,  372. 

in  scarlet  fever,  240. 

in  smallpox,  300. 

in  typhus,  338. 


I. 


Immunity  from  yellow  fever,  389. 
Incubation  period 

of  anthrax,  137. 

of  beriberi,  414. 

of  cerebro-spinal  meningitis,  125. 

of  chickenpox,  313. 

of  diphtheria,  47. 

of  dysentery,  194. 

of  enteric  fever,  10. 


Incubation  period — continued, 
of  German  moaslos,  274. 
of  glandors,  146. 
of  influenza,  1 54. 
of  Kala  Azar,  208, 
of  mialaria,  105. 
of  measles,  252. 
of  mumps,  347. 
of  pellagra,  426. 
of  plague,  72. 

of  pulmonary  tuberculosis,   160. 
of  relapsing  fever,  97. 
of  rheumiatic  fever,  358. 
of  scarlet  fever,  216. 
of  smallpox,  283. 
of  typhus,  321. 
of  whooping  cough,  395. 
of  yellow  fever,  379. 
Indian  and  European  type  of  relapsing 

fever,  98. 
Indurative    mediastino-pericarditis    in 

rheumatic  fevei,  366, 
Infection  in  anthrax,  143. 

in  beriberi,  421  to  424. 

in  cerebro-spinal  meningitis, 

134. 
in  chickenpox,  319, 
in  cholera,  92,  93. 
in  diphtheria,  69, 
in  dysentery,   amoebic,   206  ; 

bacillary,  198. 
in  enteric  fever,  42. 
in  German  measles,  281. 
in  glanders,  152. 
in  influenza,  164. 
in  Kala  Azar,  214, 
in  malaria,  123. 
in  measles,  270. 
in  mnmps,  356. 
in  plague,  79, 
in  pulmonary   tuberculosis, 

188. 
in  relapsing  fever,  103, 
in  rheumatic  fever,  377. 
in  scarlet  fever,  247. 
in  smallpox,  305. 
in  typhus,  343. 
in  whooping  cough,  411, 
in  yellow  fever,  389, 
Infectivity  of  antlirax,  144. 

of  cerebro -spnial  meningitis 

135. 
of  chickenpox,  319. 
of  cholera,  93. 
of  diphtheria,  69. 
of  dysentery,  amoebic,  206  ; 

bacillary,  198. 
of  enteric  iever,  42. 


HH    2 


456 


Index 


Infeetivity — continued. 

of  German  measles,  281. 

of  glanders,  152. 

of  influenza,  1 64. 

of  Kala  Azar,  215. 

of  measles,  270. 

of  mumps,  356. 

of  plague,  80. 

of  pulmonary  tuberculosis, 
189. 

of  scarlet  fever,  248. 

of  smallpox,  305. 

of  typhus,  344. 

of  whooping  cough,  411. 

of  yellow  fever,  391. 
Influenza,  154  to  165. 

Aching  in  Hmbs  in,  155. 
Alcohol  in,  163. 
Bronchitic  type  of,  155. 
Cardiac  failiore  in,  156. 
Catarrhal  symptoms  in,  155. 
Catarrhal  type  of,  155. 
Cerebral  or  nervous  type  of,  157. 
Clinical  types  of,  154  to  158. 
Complications  of,  159. 
Convalescence  from,  155,  156,  160. 
Cough  in,  155,  156. 
Death  rate  in,  164. 
Delirium  in,  156,  157. 
Diagnosis  of,  158. 
Diarrhoea  in,  156. 
Diet  in,  163. 
Epidemiology  of,  163. 
Febrile  type  of,  154. 
Gastro-intestinal  type  of,  156. 
Headache  in,  154,  157. 
Home  prophylaxis  of,  165. 
Hypnotics  in,  162. 
Incubation  period  of,  154. 
Infection  in,  164. 
Infeetivity  of,  164. 
Inhalations,  dry,  in,  162. 
Invasion  of,  154,  157. 
Lachrymation  in,   155. 
Lumbar  piincture  in,  158. 
Mild  cases  of,  157. 
Nervous  or  cerebral  type  of,  157. 
Physical  signs  in  chest  in,  156. 
Pneumonia,  lobar,  in,  156. 
Public   health    administration   of, 

165. 
Pulse  in,  155,  157. 
Respiration  in,  155. 
Rigor  in,    154. 
Sequelae  of,  160. 
Sputum  in,  156. 
"  Substernal  rawness  "  in,  155. 
Temperature  in,   155,  156,  157, 


Influenza — continu  ed. 

Treatment  of,   161  to   163. 
Vomiting  in,   154,   156. 
Inguinal  bubo  in  relapsing  fever,  101. 
Inhalations  in  influenza,  162. 

in  pulmonary  tuberculosis 
183. 
Injection  of  blood    serum    in    cerebro- 
spinal meningitis,   133. 
of  bullock' s  serum  in  glanders 

151. 
of  Lugol's  solution  in  glan- 
ders, 151. 
of  quinine   in    malaria,    120, 

121. 
of  saline  solution  in  cholera, 

89. 
of  saline  solution  in  relapsing 
fever,  102. 
Insomnia  after  cholera,  88. 
Insular  sclerosis  after  enteric  fever,  25. 
Intestinal  anthrax,  138. 

catarrh   in   bacillary   dysen- 
tery, 195. 
obstruction     after     amoebic 
dysentery,  202. 
Intestine,  perforation  of 

in  amoebic  dysentery,  202. 
in  enteric  fever,  17,  18. 
Intubation  in  diphtheria,  66. 
Invasion  of  anthrax,  138,  139. 
of  beriberi,  414,  417. 
of  cerebro -spinal  meningitis, 

126. 
of  chickenpox,  314. 
of  cholera,  84. 
of  diphtheria,  47. 
of  dysentery,    amoebic,    199  ;. 

bacillary,  195. 
of  enteric  fever,  11. 
of  German  measles,  275. 
of  glanders,  147,  148. 
of  influenza,  154,  157. 
of  Kala  Azar,  208,  209. 
of  measles,  254. 
of  mumps,  347. 
of  plague,  72. 
of  relapsing  fever,  98,  100. 
of  rheumatic  fever,  358. 
of  scarlet  fever,  219,  220,  222,, 

223. 
of  smallpox,  283. 
of  typhus,  322. 
of  whooping  cough,  395,  396. 
of  yellow  fever,  380. 
Ipecacuanha    in     amoebic    dysentery, 
203. 


Index 


467 


Jaundice  in  malaria,    109. 

in  rolapsing  fovor,   OS. 
in  scarlot  fovor,   2.'J2. 
in  typhus,   ',V.i2. 


K. 


Kala  Azar,  208  to  21.5. 

Acute  onset  of,  208. 

Anfemia  in,  210. 

Appetite  in,  210. 

Bacteriological  diagnosis  of,  211. 

Blood  in,  210,  211. 

Blood  in,  examination  of,  211. 

Clinical  typos  of,  208  to  210. 

Complications  of,  210. 

Death  rate  in,  215. 

Diagnosis  of,  211. 

Diet  in,  213. 

Digestion  in,  210. 

Emaciation  in,  209,  210. 

Epidemiology  of,  213. 

Haemic  murmurs  in,  210. 

Haemorrhages  in,  210. 

Home  prophylaxis  of,  215, 

Incubation  period  of,  208. 

Infection  in,  214. 

Infectivity  of,  215. 

Insidious  onset  of,  209. 

Invasion  of,  208,  209. 

Liver  in,  209. 

Liver  in,  puncture  of,  211. 

Oedema  of  feet  and  legs  in,  210. 

Petechise  in,  210. 

Public    health    administration   of, 
215. 

Quinine  in,  213. 

Rigors  in,  208. 

Spleen  in,  209. 

Spleen  in,  puncture  of,  211. 

Sweating  in,  210. 

Temperatxire  in,  208. 

Treatment  of,  213. 
Kernig's  sign  in  cerebro -spinal 

meningitis,   127. 
Keratitis  in  smallpox,  292. 
Kidneys  after  malaria,  115. 

in  scarlet  fever,  229  to  231. 
Koplik's  spots  in  measles,  253,  254. 
Kyphosis  in  typhoid  spine,  24. 


L. 


Laryngeal  diphtheria,  52. 
Laryngitis  in  chickenpox,  317. 

in  German  measles,  278. 

in  influenza,  160. 


Laryngitis — continued. 

in  moasloH,  2.')7. 
in  smallpox,  292. 
in  typhus,  330. 
in  whoof>ing  cough,  390, 
400. 
Lavorania  immaoidata,    1 1 2. 
malaria,    1  1 2. 
'prcecox,    1 1 2. 
Loishman-Donovan   bodies,    208,    211, 

212,  21.3. 
Leiter's  coil  in  relapsing  fever,  102. 
Leukocytosis  in  amoebic  dysentery,  201 
in  enteric  fever,  27. 
in  malaria,  1 1 2. 
in  pellagra,  430. 
in  pulmonary  tuber- 
culosis, 443. 
in  rheumatic  fever,  363. 
in  whooping  cough,   403. 
Leukopsenia  in  enteric  fever,  27. 

in  Kala  Azar,  210,  211. 
Liver   after  malaria,  115. 
in  Kala  Azar,  209. 
in  plague,  73. 

in  pulmonary  tuberculosis,  168. 
in  relapsing  fever,  98. 
puncture  of,  in  Kala  Azar,  211. 
Lugol's  solution,  151. 
Lumbar  puncture 

in  cerebro -spinal  meningitis,  130. 
in  influenza,  158. 
Lungs,  collapse,  after  measles,  260. 
in  whooping  cough, 
400. 
in  glanders,  148. 
in  pulmonary  tviberculosis,  167 
to   175. 
Lymph  channels  in  anthrax,  138. 
Lymphangitis  in  enteric  fever,  22. 
in  glanders,  151. 
in  typhus,  331. 
Lymphatic  glands,  suppuration  of,  in 

glanders,  151. 
Lysis,  definition  of,  2. 

M. 

Maize  or  Zeist  theory  of  pellagra,  434. 
Malaria,  105  to  124. 

Aestivo -Autumnal,  108. 

Alcohol  in,  117. 

Algide  form  of,  109. 

Bacteriological  diagnosis  of,  109  to 
113. 

Bilious  remittent  type  of,  109. 

Blood  in,  112. 


458 


Index- 


Malaria — continued. 

Blood  in,  examination  of,   109  to 
113. 

Cardiac  failure  in,  109. 

Cerebral  symptoms  in,  109. 

Clinical  tyijes  of,  105  to  109. 

Cold  stage  in,  106,  108. 

Complications  of,  113. 

Diagnosis  of,  109  to  113. 

Diarrhoea  in,  109. 

Diet  in,  212. 

Double  tertian,   107. 

Epidemiology  of,   122. 

Haemorrhages  in,  109. 

Headache  in,  106. 

Home  prophylaxis  of,  123. 

Hot  stage  in,  106,  108. 

Incubation  period  of,  105. 

Infection  in,  123. 

Injection  of  quinine  in,   Bacelli's 
intravenous,  120,  121. 

Injection    of    quinine    in,    intra- 
muscular, 117,  118. 

Jaundice  in,  109. 

Malignant  or  sestivo- autumnal,  108 

Mild  types  of,  109. 

Mixed  infection  in,  1 09. 

Public   health    administration   of, 
124. 

Pulse  in,  106. 

Quartan,  107. 

Quotidian  character  of,  107. 

Quinine  in,  117  to  120. 

Remittent  type  of  malignant,  108. 

Respiration  in,  106. 

Rigor  in,  106,  108. 
-    Sequelse  of,  113  to  115. 

Spleen  in,  107,  114. 

Sweating  in,  106,  108,  109. 

Sweating  stage  of,  106,  108. 

Temperature  in,  106,  108,  109. 

Tertian,  105  to  107. 

Treatment  of,  116  to  120. 

Treatment  of  sequelae  of,  120,  121. 

Urine  in,  107. 

Vomiting  in,  106,  109. 
Malarial  cachexia,  113,  114. 

Malignant  or  sestivo -autumnal 

malaria,   108. 
"  Malignant  parasite  "  of  malaria.  111. 
Malignant  pustule.     See  anthrax. 
Malleinisation  in  glanders,  151. 

Mania  after  typhus,  332. 

in  pellagra,  43 1 . 
Manson,  Sir  Patrick,  81,  94,  112,  115, 
122,  123,  205,  208,  213,  386. 


Mastitis  in  mumps,  349,  350. 
Mastoid  abscess  in  scarlet  fever,  226. 

periostitis  in  scarlet  fever,  226. 
Measles,  252  to  273. 

Asthenic  type  of,  256. 
Catarrhal  symptoms  in,  254. 
Clinical  types  of,  254. 
Complications  of,  256. 
Complication  by  other  infectious 

diseases,  259. 
Convalescence  from,   255. 
Cough  in,  254. 
Death  rate  in,  270. 
Desquamation  in,  253. 
Diagnosis  of,  261. 
Diet  in,  269. 
Epidemiology  of,  269. 
Eyes  in,  254. 
Facies  of,  254. 
Fulminant  tj^es  of,  255. 
Home  prophylaxis  of,  271. 
Incubation  period  of,   252. 
Infection  in,  270. 
Infectivity  of,  270. 
Invasion  of,  254. 
Koplik's  spots  in,  253,  254. 
Mild  types  of,  255. 
Prodromal  rashes  in,  253. 
Public    health   administration   of, 

272. 
Pulse  in,  256. 

Rash  in,  252,  253,  254,  255,  256. 
School  epidemics  of,  272. 
Second  and  third  attacks  of,  271. 
Sequelae  of,  260. 
Temperature  in,  254. 
Treatment  of,  262. 
Treatment    of    complications    of, 

263  to  268. 
Treatment  of  sequelae  of,  268. 
Mediastino-pericarditis,  indiu-ative,   in 

rheumatic  fever,  366. 
Melancholia  after  influenza,  161. 
in  pellagra,  429,  431. 
Meningitis  in  glanders,  150. 
in  mumps,  351. 
in  typhus,  332. 
Meningo-encephalitis  in  mumps,  351. 
Mental  deficiency  after  cerebro -spinal 
meningitis,   1 29. 
weakness  after  tj'phus,  332. 
Mesenteric  gland,  ruptiu-e  of  suppiu"at- 

ing,  in  enteric  fever,  18. 
Metrorrhagia  in  smallpox,  289. 
Micrococcus  catarrhalis,  159. 

rheumaticus,  377. 
Middle  ear  suppuration  in  Kala  Azar, 
211. 


Index 


459 


Mild  type  of  corobro-spiiial   meningitis, 
128. 
of  cholera,  80. 
of  glanders,  148. 
of  influenza,  157. 
of  malaria,  109. 
of  measles,  255. 
of  scarlet  fever,  223. 
of  typhus,  328. 
Miliary  tubercle  of  lung,  1 67. 
Milk  infection  in  enteric  fever,  45. 

in  pulmonary    tubercu- 
losis, 188. 
in  scarlet  fever,  251. 
Mixed  infections  in  malaria,  109. 
Moderate  type  of  enteric  fever,  13  to  15. 
Modification    of    typical    haemorrhagic 

smallpox,  290. 
Modified  form  of  septicsemic  plague,  75 
of  smallpox  or  varioloid, 
290. 
Mosquito  and  malaria,  105,  123. 
and  yellow  fever,  389. 
"  Mulberry  eruption  "  of  typhus,  322. 
Mumps,  347  to  357. 

Clinical  types  of,  347  to  349. 

Complications  of,  349. 

Death  rate  in,  356. 

Diagnosis  of,  352. 

Diet  in,  355. 

Epidemiology  of,  355. 

Glands  in,  347,  348. 

Home  prophylaxis  in,  356. 

Incubation  period  of,  347. 

Infection  in,  356. 

Infectivity  of,  356. 

Invasion  of,  347. 

Public   health    administration    of, 

356. 
Rash  in,  347. 
Saliva  in,  349. 
Second  attacks  of,  356. 
Sequelae  of,  351. 
Stenson's  duct  in,  348. 
Temperature  in,  349. 
Treatment  of,  354. 
Treatment  of  complications  of,  355 
Muscles,  atrophy,    permanent,    after 
beriberi,   418. 
enfeeblement  after  diphtheria, 

57. 
paresis,    in    cerebro-spinal 

meningitis,    128. 
system  after  influenza,  160. 
tetanic  spasms  in  pellagra,  431 
tremor    in    cerebro-spinal 
miningitis,  128. 


Muscles — continued. 

wasting  in  beriberi,  414. 

weakness  after  cerebro-spinal 
meningitis,  129,  134. 

weakness  in  pellagra,  429,  430. 
Myalgia  in  rheumatic  fever,  362. 
Mydriasis  in  pellagra,  430. 
Myelitis,  disseminated,  in  measles,  259. 
Myocarditis  in  rheumatic  fever,  367. 
in  scarlet  fever,  228. 


N. 


Nasal  diphtheria,  51. 
Nephritis  after  bacillary   dysentery, 
196. 
after  cholera,  88. 
after  mumps,  352. 
after  relapsing  fever,  1 02. 
chronic  tubular,  after  scarlet 

fever,  233. 
in  chickenpox,  317. 
in  diphtheria,  56. 
in  measles,  259. 
in  scarlet  fever,  229. 
in  typhus,  331. 
in  whooping  cough,  402. 
Nervous  depression  in  malaria,   113. 

irritability  in  whooping  cough, 

402. 
or  cerebral  type  of  influenza, 

157. 
symptoms  in  influenza,  157. 
symptoms    in    pellagra,    428, 

430. 
symptoms  in  scarlet  fever,  422 
system  after  influenza,  160. 
Neurasthenia  after  enteric  fever,  23. 

after  influenza,  1 60. 
Neuritis,  multiple,  after  relapsing  fever, 
102. 
optic,  in  cerebro-spinal 

meningitis,  129. 
optic,  in  influenza,  1 60. 
peripheral,  after   influenza, 
160. 
after  malaria,  115. 
after  mumps,  352. 
after  typhus,  332. 
in  bacillary 

dysentery,  1 95. 
in  beriberi,  417. 
in  enteric  fever,  23, 
in  measles,  259. 
in  smallpox.  293. 
Nem-oses  after  malaria,  114. 
Nodules  in  scarlet  fever,  229. 


460 


Index 


Noma  in  measles,  259. 
Nursing,  9. 

Nystagmus  in  cerebro-siDinal  meningitis 
,129. 


O. 


Ocular  symiDtoms  in  iDellagra,  430. 
Odoiu'  of  rheumatic  fever,  360. 

of  typhus,  326. 
Oedema  in  beriberi,  417. 

in  Kala  Azar,  210. 

in  pvilmonary  tuberculosis, 

172. 
of  glottis  in  smallpox,  293. 
Open-air    treatment 

of  pulmonary  tuberculosis,  175. 
of  whooping  cough,  405,  406. 
Ophthalmia  after  relapsing  fever,  102. 
Opisthotonos    in    cerebro -spinal 

meningitis,   127,   128. 
Opsonic  index 

in  cerebro -spinal   meningitis,    132. 
in  pulmonary  tuberculosis,  443. 
Optic  disc,  hyperaemia  of,  in  cerebro- 
spinal meningitis,  128. 
Orchitis  in  mumps,  349,  350. 

in  smallpox,  293. 
Ornithodoriis   moubata,    103. 
Osteo-myelitis  in  scarlet  fever,  227. 
Otitis  media 

chronic,  after  measles,  260. 
chronic,  after  scarlet  fever,  233. 
chronic,  after  whooping  cough,  403 
in  cerebro-spinal  meningitis,   128. 
in  diphtheria,  56. 
in  influenza,  160. 
in  measles,  258. 
in  scarlet  fever,  226. 
in  typhus,  332. 
Ovaries,   inflammation  of,   in  mumps, 
349,  350. 


P. 


Palsy,  facial,  after  mumps,  351. 
Palsies,  diphtheritic,  58,  59. 
Pancreatitis  in  mumps,  350. 
Panophthalmitis  in  measles,  258. 

in  smallpox,  291. 
Paraplegia  after  typhvis,  332. 
in  smallpox,  293. 
Paratyphoid  fever,  27. 
Parotid    swelling,    suppuration    of,    in 
mumps,  351. 


Parotitis,  acute  suppurative,  in  cholera 
88. 
in  influenza,  160. 
in  relapsing  fever,  101. 
in  typhus,  331. 
in  yellow  fever,  383. 
Paroxysm  of  whooping  cough,  397. 
Paroxysmal  stage  of  whooping  cough, 

397. 
PeUagra,  426  to  438. 

Acute  form  of,  430. 

Arsenic  in,  438. 

Blood  in,  430. 

Bowels  in,  428. 

in  British  Isles,  432,  433. 

Clu-onic  form  of,  431. 

Clinical  types  of,  427. 

Convulsions  in,  431. 

Delirimn  in,  431. 

Dementia  in,  429. 

Diarrhoea  in,  428. 

D\u-ation  of,  429. 

Emaciation  in,  429. 

Epidemiology  of,  431. 

Etiology  of,  434  to  438. 

Gastro -intestinal     symptoms     in, 
427,  430. 

Gums  in,  430. 

Hallucinations  in.  431. 

Headache  in,  428. 

Incubation  period  of,  426. 

in  United  States  of  America,  432. 

Maize  or  Zeist  theory  in,  434. 

Mania  in,  431. 

Melanchoha  in,  429,  431. 

Muscles  in,  tetanic  spasms  of,  431. 

Muscular  weakness  in,  429,  430. 

Nervous  symptoms  in,  428,  430. 

Ocular  symptoms  in,  430. 

Periodic     exacerbations     and    re- 
missions in,  428,  429. 

Pulse  in,  430. 

Rash  in,  427,  428. 

Reflexes,  deep,  in,  429. 

Sex  incidence  of,  434. 

Simuliidae  and,  436,  437. 

Skin  in,  429,  430. 

Stools  in,  428. 

Temperature  in,  430,  431. 

Tongue  in,  427,  428,  430. 

Treatment  of,  438. 

Urine  in,  430. 

Vertigo  in,  427,  428,  430. 

Zeist  or  maize  theory  in,  434. 
Pericarditis  after  whooping  cough,  403. 
indm-ative   mediastino,   in 
rheumatic  fever,  366. 
in  bacillary  dysentery,  196 


Index 


461 


Pericarditis — confirm  ed. 

in  p;lantlors,  I  50. 
in.  infhionza,  If)!*, 
in  moaHlos,  259. 
in  rheumatic  fovor,  364. 
in  scarlet  fever,  228. 
Period   of  calm  in  yellow  fever,  381. 

of  reaction  in  yellow  fever,  381. 
Periodic  exacerbation  and  remission  of 

pellagra.  428,  429. 
Periostitis  in  scarlet  fever,  227. 
Periproctitis  in  bacillary  dysentery,  195 
Perispondylitis  in  "  typhoid  spine,"  25. 
Peritonitis  after  measles,  260. 

ill  bacillary  dysentery,  195. 
in  enteric  fever,  19. 
Perityphlitis  in  bacillary  dysentery,  195. 
Permanganates  in  cholera,  90. 
Pestis  Minor.     *S'ee  Plague. 
Peyer's  patches  in  enteric  fever,  10. 
Pharyngitis  in  pellagra,  430. 
Photophobia  in  cerebro -spinal 

meningitis,  127. 
in  measles,  258. 
Phthisis.     See  Pulmonary  Tuberculosis 
Physical  signs  in  chest 
in  influenza,   156. 

in  pulmonary     tuberculosis,     167, 
168,  169,  170,  171,  172. 
"  Pink  eye  "  in  German  measles, 

275,  277. 
Pitting  after  smallpox,  294. 
Plague,  72  to  83. 

Ambulatory  form  of,  76. 

Antitoxic  serum  in,  78,  79. 

Bacteriological  diagnosis  of,  77. 

Bubonic,  74. 

Clinical  types  of,  73  to  76. 

Complications  of,  78. 

Death  rate  in,  81. 

Delirium  in,  73,  75. 

Diagnosis  of,  76. 

Diarrhoea  in,  75. 

Epidemiology  of,  79. 

Facies  of,  73. 

Fleas  and,  80. 

Glasgow  epidemic  of  1900,  74,  75, 

77,  80,  82,  83. 
Haemorrhages  in,  75. 
Headache  in,  73. 
Hj^pnotics  in,  78. 
Incubation  period  of,  72. 
Infection  in,  79. 
Infectivity  of,  80. 
Invasion  of,  72. 
Liver  in,  73. 


Plague — continved. 

Modified  form  of  septicf/jmic,  75. 

Personal  prophylaxis  in,  81. 

Pestis  minor,  76. 

Pneumonic,  76. 

Public    health    administration    of, 

82,  83. 
I'ulso  in,  73, 
Kash  in,  72. 
Respiration  in,  73,  76. 
SepticEcmic,  75, 
Sequela;  of,  78. 
Spleen  in,  73. 
Sputum  in,  76. 
Stage  of  fever  in,  73. 
Subsultus  tendinum  in,  73. 
Suffolk  epidemic  of  1910,  77. 
Temper atiu-e  in,  73,  76. 
Tongue  in,  73. 
Treatment  of,  78. 
Urine  in,  73. 

retention  of,  73. 
Vomiting  in,  73. 
Pleiu-isy  in  cholera,  88. 

in  bacillary  dysentery,  195. 
in  enteric  fever,  22. 
in  influenza,  1 60. 
in  measles,  257. 
in  pulmonary  tuberculosis,  169 
in  rheumatic  fever,  367. 
in  scarlet  fever,  231. 
in  smallpox,  292. 
with     effusion     in     whooping 
cough,  400. 
Pneumonia  in  cholera,   88. 

in  Kala  Azar,  210. 
in  rheumatic  fever,  367. 
lobar,  in  influenza,  156. 
lobar,  in  measles,  257. 
lobar,  in  relapsing  fever, 

101. 
lobar,  in  smallpox,  292. 
lobar,  in  typhus,  330. 
lobar,  in  whooping  cough, 

400. 
subacute,  in  glanders,  147 
Pneumonic   phthisis,   168. 

plague,  76. 
Pneumothorax 

artificial,    in   pulmonary   tuber- 
culosis,   184. 
in  pulmonary  tuberculosis,  186. 
Poliomyelitis,     acute     anterior,     after 

measles,  260. 
Post-pharyngeal     abscess     in     scarlet 

fever,  226. 
Pregnancv,  smallpox  complicated  by, 
293. 


462 


linh 


Prodromal  rasli  in  enteric  fever,  12. 
in  measles,  253. 
in  smallpox,  286. 
Prolapse  of  rectum  in  whooping  cough, 

402. 
Prophylactic  inoculations 

against  cholera,  96. 

against  plagvie,  82. 
Prophylaxis,  8. 

in  anthrax,  144. 

in  beriberi,  424. 

in  cerebro-spinal  meningitis,  135. 

in  chickenpox,  320. 

in  cholera,  94. 

in  diphtheria,  7.0. 

in  dysentery,  amoebic,  206  ; 
bacillary,  199. 

in  enteric  fever,  44. 

in  Gerinan  measles,  281. 

in  glanders,  152. 

in  influenza,  165. 

in  Kala  Azar,  215. 

in  malaria,  123. 

in  measles,  271. 

in  mumps,  356. 

in  plague,  81. 

in  pvilmonary  tuberculosis,  189  to 
191. 

in  relapsing  fever,  103. 

in  scarlet  fever,  249. 

in  smallpox,  306. 

in  typhus,  344. 

in  whooping  cough,  412. 

in  yellow  fever,  392. 
Pseudo -crisis,  definition  of,  2. 
Psychasthenic   manifestations   after 

influenza,  161. 
Ptosis  in  pellagra,  430. 
Public  health  administration 

of  anthrax,  145. 

of  cerebro-spinal  meningitis,  136. 

of  chickenpox,  320. 

of  cholera,  94,  95. 

of  diphtheria,  71. 

of  dysentery,    amoebic,    207  ; 
bacillary,  198. 

of  enteric  fever,  45. 

of  German  measles,  282. 

of  glanders,  153. 

of  influenza,  165. 

of  Kala  Azar,  215. 

of  malaria,  124. 

of  measles,  272. 

of  mvimps,  356. 

of  plague,  82,  83. 

of  piilmonary  tuberculosis,  191  to 
.    19.3. 


Public  health  administration — 

continued. 

of  relapsing  fevei ,  104. 

of  scarlet  fever,  250. 

of  smallpox,  306. 

of  typhus,  345. 

of  whooping  cough,  412. 
Pulmonary   anthrax,   139. 

catarrh  after  measles,  260. 
Pulmonary   tuberculosis,    166   to    193, 
439  to  443. 

Absolute  rest  in,  179. 

Artificial  pneumothorax  in,  184. 

Bacteriological  diagnosis  of,  174. 

Blood  in,  examination  of,  442. 

Broncho -pneumonic  lesion  in,  168, 

Calmette's  reaction  in,  175. 

Chronic    phthisis    with    softening, 
169. 

Climatic  treatment  of,  175. 

Clinical  types  of,  167  to  172. 

Collateral  catarrh  in,  169. 

Complications  of,  172. 

Contra-toxin,  No.  4  (Mehnarto)  in, 
439  to  443. 

Cough  in,  168,  169,  172,  184,  442. 

Death  rate  in,  189. 

Diagnosis  of,  173. 

Diet  in,  187. 

Emaciation  in,  170. 

Epidemiology  of,  187. 

Examination  of  chest  in,  175. 

Excavation  in,  169. 

Exercise,  graduated,  in,  179,  180. 

Fibroid  phthisis,  171. 

Hfemoptysis  in,  170,  172,  186. 

Heredity  of,  174,  189. 

Home  prophylaxis  in,  189  to  191. 

Hydropneumothorax  in,  186. 

Incubation  period  of,  166. 

Infection  in,  188. 

Infectivity  of,  189. 

Inhalation,  continuous,  in,  183. 

Liver  in,  168. 

Miliary  tubercle  of  king,  167. 

Milk  infection  in,  188. 

Oedema  of  legs  and  feet  in,  172. 

Open-air  treatment  of,  175. 

Opsonic  index  in,  443. 

Pleurisy  in,  169. 

Pneumonic  phthisis,  168. 

Pneumothorax  in,  186. 

Public    health    administration    of, 
191  to  193. 

Pulse  in,  167. 

Rash  in.  167. 

Respiration  in,  167. 

Rigor  in,  168. 


index 


463 


Pulmonary  tuberculosis — continued. 
Sanatorium  treatment  of ,  176,  182, 

183. 
Serum  treatment  of,  439  to  443. 
(Also  Sm  Contra-toxin,  No.  4 
(Mehnarfco).) 
Softening  of  lung  in,  168,  169. 
Spleen  in,  168. 

Sputum  in,  168,  169,  172,  442. 
Sputum  in,  examination  of,    174. 

442. 
Sputum    "  nummular,"    m,     169. 
Sweats  in,  174. 

Temperature  in,   167,   168,   169. 
Temperature  observation  in,   174, 

178. 
Treatment  of,  175  to  185. 
Tuberculin  in,  181  to  183. 
Tuberculin  test  in,  175. 
Vaccine  therapy  in,  180. 
Von  Pirquet's  test  in,  175. 
X-rays  in,  175. 
Pulse  in  anthrax,  139. 
in  beriberi,  416. 

in  cerebro- spinal  meningitis,  127 
in  cholera,  85. 
in  diphtheria,  48,  49,  51. 
inbacillary  dysentery,  195. 
in  enteric  fever,  13,  17. 
in  influenza,  155,  157. 
in  malaria,  106. 
in  measles,  256. 
in  pellagra,  430. 
in  plague,  73. 

in  pvilmonary  tuberculosis,  167. 
in  relapsing  fever,  98. 
in  rheumatic  fever,  358,  361. 
in  scarlet  fever,  220,  222. 
in  smallpox,  284,  287,  288,  289. 
in  typhus,  323,  324,  326,  327. 
in  whooping  cough,  398. 
in  yellow  fever,  380,  383. 
Pupils  in  cerebro -spinal  meningitis,  127 
Ptirgatives  in  enteric  fever,  33. 
in  yellow  fever,  385. 
Purpura  after  malaria,  114. 
Pustulation  in  smallpox,  prevention  or 

modification  of,   303. 
Pyiemic    manifestations    in    bacillary 

dysentery,  195. 
Pyelitis  in  enteric  fever,  22. 
Pyogenic  infection  of  tliroat,  secondary, 
in  diphtheria,  56. 


Q. 


Quarantine  in  cholera,  95. 


Quartan  malaria,  107. 

parasite,   1 1 1. 
Quinine  in  blackwator  f over,  115,  116. 

in  Kala  Azar,  213. 

in  malaria,   117  to   120,   121. 
Quotidian  character  of  malaria,  107. 

R. 

Rash  in  cerebro -spinal  rnoningitis,  1 25. 
in  chickenpox,  313,  314,  315,  316. 
in  cholera,  84. 
in  enteric  fever,  10. 
in  German  measles,  274,  276. 
in  glanders,  146. 

in  measles,  252,  253,  254,  255,  256 
in  pellagra,  427,  428. 
in  plague,  72. 
in  relapsing  fever,  97. 
in  rheumatic  fever,  358. 
in  scarlet  fever,  216,  222,  223,224 
in  smallpox,  284  to  286,  287. 
in  typhus,  321. 
in  yellow  fever,  379. 
Rats  and  plague,  80. 
Rectal  feeding  in  whooping  cough,  410 
Reflexes,  deep,  in  beriberi,  415,  417. 

deep,  in  pellagra,  429. 

knee,  in  cerebro -spinal 
meningitis,  127. 

knee,  in  enteric  fever,  24,  25. 

knee,  in  smallpox,  293. 

plantar,  in  cerebro -spinal 
meningitis,  127. 

plantar,  in  enteric  fever,  25. 

superficial,  in  beriberi,  415. 
Relapse  in  cerebro-spinal  meningitis, 
129. 

in  cholera,   87. 

in  enteric  fever,  29. 

in  relapsing  fever,  99. 

in  yellow  fever,   392 
Relapsmg  fever,  97  to  104. 
African  type  of,  100. 
Alcohol  in,  102. 

Bacteriological  diagnosis  of,  101. 
Bleeding  in,  102. 
Blood  in,  examination  of,  101. 
Cardiac  failure  in,  100. 
Clinical  types  of,  97  to  100. 
Complications  of,  101. 
Constipation  in,  99. 
Crisis  in,  99. 
Death  rate  in,  103. 
Delirium  in.  98. 
Diagnosis  of,   100,   101. 
Diarrhoea  in.  99. 
Diet  in,   102 


464 


Index 


Relapsing  fever — continued. 
Diuretics  in,   102. 
Emetics  in,   102. 
Epidemiology  of,   103. 
Epistaxis  in,  99. 
European  or  Indian  type  of,  98. 
HEemorrhages  in,  100. 
Headache  in,  98. 
Home  prophylaxis  in,  103. 
Hypnotics  in,  102. 
Incubation  period  of,  97. 
Indian  or  European  type  of,  98. 
Infection  in,  103. 
Injections,    intracellular,     of    hot 

saline  solution  in,  102. 
Invasion  of,  98,  100. 
Jaundice  in,  98. 
Liver  in,  98. 
Public    health    administration    of, 

104. 
Pulse  in,  98. 
Rash  in,  97. 
Relapses  in,  99. 
Respiration  in,  98. 
Rigors  in,  98. 
Sequel*  of,  102. 
Sleeplessness  in,  98. 
Stools  in,  98. 
Sweating  in,  99. 
Temperature  in,  98. 
Tongue  in,  98. 
Treatment  of,   102. 
Uraemia  in,   100. 
Urine  in,  98. 

Urine  in,  suppression  of,  100. 
Vomiting  in,  98,  100. 
Remittent  type  of  malignant  malaria, 

108. 
Respiration  in  anthrax,  139. 

in  cholera,  85. 

in  enteric  fever,  13. 

in  influenza,  155. 

in  malaria,  106. 

in  plague,  73,  76. 

in  pulmonary  tuberculosis, 
167. 

in  relapsing  fever,  98. 

in  scarlet  fever,  222. 

in  typhus,  323,  324. 

in  yellow  fever,  380. 
Rheumatic  fever,  358  to  378. 
Alkaline  treatment  of,  371. 
Anfemia  in,  363,  373. 
Bacteriology  of,  377. 
Blood  in,  363, 
Blood  pressure  in,  363. 
Cardiac     complications     in,     362, 
363  to  367. 


Rheumatic  fever  -continued. 

Children,  rheumatic  fever  in,  362. 

Climatology  of,  378. 

Clinical  types  of,  358  to  363. 

Complications  of,  363. 

Constijaation  in,  374. 

Convalescence  from,  361,  373. 

Deliriixmin,  361. 

Diagnosis  of,  368. 

Diet  in,  376. 

Duration  of  attack  of,  360. 

Facies  of,  359. 

Grave  type  of,  361. 

Hypnotics  in,  372. 

Incubation  period  of,  358. 

Infection  in,  377. 

Invasion  of,  358. 

Joints  in,  358,  359,  360. 

Myalgia  in,  362. 

Nodules  in,  368. 

Odour  in,  360. 

Pulse  in,  358,  361. 

Rash  in,  358. 

Salicylate  treatment  of,  372. 

Second  and  third  attacks  of,  363. 

Skin  in,   359. 

Sleeplessness  in,  360. 

Sore  throat  in,  358. 

Sweats  in,  360. 

Temperature  in,  358,  361,  362. 

Tongue  in,  358. 

Treatment  of,  371. 

Treatment    of,    complications    of, 
375. 

Urine  in,  360. 
Rheumatic  nodules  in  rheumatic  fever, 
368. 
nodules  in  scarlet  fever,  229 
symptoms  in  glanders,  148. 
Rhinitis  in  scarlet  fever,  225. 
Rice  theory  of  beriberi,  421  to  424. 

Rice-water    appearance    of    stools    in 
cholera,  85. 

Rickets  after  measles,  260. 

after  whooping  cough,  402. 

Rigor  in  cerebro-spinal  meningitis,  126 

in  enteric  fever,  14. 

in  influenza,  154. 

in  Kala  Azar,  208. 

in  malaria,  106,  108. 

in  pulmonary  tuberculosis,  168. 

in  relapsing  fever,  98. 

in  scarlet  fever,  219,  221. 

in  smallpox,  283. 

in  typhus,  322. 
Rose-spots  in  enteric  fever,  10. 


Index 


465 


S. 

Salicylate     treatment     of     rheumatic 

fever,  372. 
Saliva  in  mumps,  349. 

Salvarsan,  213. 

Sanatorium   treatment   of   pulmonary 

tuberculosis,  176,  182,  183. 
Scarlatina  Anginosa,  222. 

Maligna,  220. 

Simplex,  219. 
Scarlatinal  rheumatism,  228. 

Scarlet  fever,  216  to  251. 
Alcohol  in,  240. 
Bacteriology  of,  237. 
Clinical  types  of,  219  to  224. 
Collar-neckin,  222,  227. 
Complication  by  other  infectious 

diseases,  232. 
Complications  of,  224. 
Death  rate  in,  249. 
Delirium  in,  220,  221. 
Desquamation  in,  218,  224. 
Diagnosis  of,  234  to  238. 
Diarrhoea  in,  221,  232. 
Diet  in,  246. 
Diuretics  in,  246. 
Epidemiology  of,  247. 
Eyes  in,  220. 
Facies  of,  220. 
Glands  in,  220,  222. 
Headache  in,  219,  221. 
Home  prophylaxis  in,  249. 
Hypnotics  in,  240. 
Incubation  period  of,  216. 
Infection  in,  247. 
Infectivity  of,  248. 
Invasion  of,  219,  220,  222,  223. 
Mild  forms  of,  223. 
Milk  supply  in,  251. 
Nervous  symptoms  in,  222.  _ 
Public   health   administration   of, 

250. 
Pulse  in,  220,  222. 
Rash  in,  216,  222,  223,  224. 
Respiration  in,  222. 
Rigor  in,  219,  221. 
Scarlatiiia  Anginosa,  222. 

Maligna,  220. 

Simplex,  219. 
School  epidemics  of,  251. 
Second  attacks  of,  249. 
Sequelae  of,  232. 
Sloughing  of  tonsils  in,  223. 
Sore  throat  in,  219. 
Temperature  in,  220,  221,  223. 


Scarlet  fever — continued. 
Tongue  in,  219,  220. 
TonBJlH  in,  219,  222. 
Treatment  of,  238  to  246. 
Treatment  of  complicationH  of, 

241. 
Vomiting  in,  219,  221. 
ScliistOHommn,  hawMtohiam,   203. 

Japonicnm,,   196,  203. 
Mansoni,  196,  203. 
School  epidemics  of  measles,  272. 

of  scarlet  fever,  251. 
Schiiffner's  dots,  110. 

Schulze's   micrococcus,   237. 

Sclavo's  anti-anthrax  serum,  142. 

Scoliosis  in  "  typhoid  spine,"  24. 

Second  attacks  of  chickenpox,  320. 

of  German  measles,  281 

of  measles,  271. 

of  mumps,  356. 

of  rhevimatic  fever,  363 

of  scarlet  fever,  249. 

of  smallpox,  306. 

of  typhus,  344. 

of  yellow  fever,  392. 
Septicsemic  plague,  75. 

Sequelae  of  beriberi,  418. 

of  cerebro- spinal     meningitis, 
129. 

of  chickenpox,  317. 

of  cholera,  88. 

of  diphtheria,  57  to  59. 

of  dysentery,    amoebic,    202  ; 
bacillary,  196. 

of  enteric  fever,  23. 

of  German  measles,  278. 

of  glanders,  151. 

of  influenza,  160. 

of  malaria,  113  to  115. 

of  measles,  260. 

of  mumps,  351. 

of  plague,  78. 

of  relapsing  fever,  102. 

of  scarlet  fever,  232. 

of  smallpox,  294. 

of  typhus,  332. 

of  whooping  cough,  402. 
Serimi,  Anti-anthrax,  142. 

Anti-diphtheritic,  50,  60  to  62. 
Anti-meningococcal,    132,    133. 
Antitoxic,  in  plague,  78,  79. 
Antityphoid,  42. 
of  Borrel  in  plague,  78. 
of  Calmette  in  plague,  78. 
of  Chantemesse  in  enteric  fever, 
42. 


466 


Index 


Serum — continued. 

of  Flexner     in     cerebro-spinal 

meningitis,  133. 
of  Sclavo  in  anthrax,  142. 
of  Yersin  in  plague,  78,  79. 
Serum  disease,  61. 

and  Contra-toxin  No.  4  (Mehnarto) 
439. 
Serum  therapy 

in  anthrax,  142. 

in  cerebro-spinal   meningitis,    132, 

133. 
in  diphtheria,  50,  60  to  62. 
in  enteric  fever,  42. 
in  plague,  78,  79. 
in  pulmonary  tuberculosis,  439  to 

443. 
in  smallpox.  303. 
Severe  type  of  enteric  fever,  15,  16. 
of  rheumatic  fever,  361. 
of  typhus,  327. 
of  yellow  fever,  382. 
Sex  incidence  of  pellagra,  434. 
Simidiida  and  pellagra,  436,  437. 
Skin  in  pellagra,  429,  430. 

in  rheumatic  fever,  359. 
in  smallpox,  283. 
in  yellow  fever,  381. 
Sleeplessness  in  enteric  fever,  98. 

in  rheumatic  fever,  360. 
in  scarlet  fever,  241. 
in  typhus,  323. 
Sloughing  in  cholera,  88. 

in  amcsbic  dysentery,  199. 
in  Kala  Azar,  211. 
in  scarlet  fever,  223. 
in  smallpox,  291,  292. 
Smallpox,  283  to  312. 
Abortion  in,  293. 
Abortion  of  attack  of,  304. 
Alcohol  in,  301,  304. 
Black  or  hsemorrhagic,  289. 
Clinical  types  of,  286  to  291. 
Complications  of,  291. 
Convalescence  from,  288,  289,  304. 
"  Crusting  "  in,  288. 
Death  rate  in,  305. 
Delirium  in,  288,  290,  293. 
Diagnosis  of,  294  to  299. 
Diagnosis  in  stage  of  eruption  of, 

295. 
Diagnosis  in  stage  of  invasion  of, 

294. 
Diagnosis  in  vesicular  stage  of,  296 
Diarrhoea  in,  288. 
Diet  in,  304. 
Epidemiology  of,  305. 
Facies  of,  289. 


Smallpox — contiuned. 
Haematuria  in,  290. 
Hasmorrhages  in,  289,  290. 
Hsemorrhagic  or  black,  289. 
Haemorrhagic,  percentage  of  cases 

in  epidemics  of,  290. 
Headache  in,  283. 
Home  prophylaxis  in,  306. 
Hypnotics  in,  300. 
Incubation  period  of,  283. 
Infection  in,  305. 
Infectivity  of,  305. 
Invasion  of,  283. 
Metrorrhagia  in,  289. 
Modification    of    typical    hsemorr- 
hagic, 290. 
Pain  in  back  in,  283. 
Poultices  in,  30J. 
Prodromal  rashes  in,  286. 
Public   health   administration   of, 

306. 
Pulse  in,  284,  287,  288,  289. 
Pustulation     in,     prevention     or 

modification  of,  303. 
Rash  in,  284  to  286,  287. 
Reflexes  in,  knee,  293. 
Rigor  in,  283. 
Second  attacks  of,  306. 
Sequelae  of,  294. 
Serum  therapy  in,  303. 
Skin  in,  283. 
Subconjunctival  hsemorrhages  in, 

289,  290. 
Subsviltus  tendinum  in,  288. 
Temperature  in,  283,  285,  287,  288. 

289. 
Treatment  of,  299. 
Treatment    of,    complications    of, 

302. 
Urine  in,  289. 
Vaccination  in,   304,   306,   307  to 

312. 
Variola  Vera,  discrete  form,  286, 

288. 
Variola  Vera,  confluent  form,  286. 
Varioloid,  290. 
Vomiting  in,  283. 
Softening  of  lung  in  pulmonary  tuber- 
culosis, 186,  169. 
Sore  throat  in  rheumatic  fever,  358. 

in  scarlet  fever,  219. 
Spa  treatment 

in  dysentery,    amoebic,    205 ; 

bacillary,  198. 
in  malaria,  121. 
Spirillum  Duttoni,  97,  101. 

recurrentis  of  Obermeier,  97,  101, 

385. 


7/1  (lex 


467 


Spleen,  embolus  of,  in  relapsing  fever, 
101. 

in  anthrax,  138,  130. 

in  enteric  f over,  13. 

in  Kala  Azar,  209. 

in  malaria,  107,  114,  115. 

in  plague,  73. 

in  pulmonary  tuberculosis,  1G8. 

puncture  of,  in  anthrax,  140. 

puncture  of,  in  enteric  fever,  29 

puncture  of,  in  Kala  Azar,  211. 

puncture  of,  in  malaria,  114. 

rupture  of,  in  relapsing  fever, 
101. 
Spondylitis  in  "  typhoid  spine,"  25. 

Sporozoon  of  malaria,  105. 

"  Spotted  fever."     See  Cerebro- Spinal 

Meningitis. 
Sputum,  examination  of,  in  pulmonary 
tuberculosis,  174,  442. 
in  anthrax,  139. 
in  influenza,  156. 
in  plague,  76. 

in  pulmonary  tuberculosis,  168, 
169,  172,  442. 
Squint  in   cerebro -spinal   meningitis, 
128. 
in  diphtheria,  58. 
Stain,  Jenner's,  101,  110,  131. 

Leishman's,  101,  110,  212. 
Neisser's,  55. 
Romano  wsky's,  110. 
Stegomyia  fasciata  and  yellow  fever,  389 

Stenson's  duct  in  mvnnps,  348. 

Stimulants  in  typhus,   340.     Also  see 

Alcohol. 
Stomatitis  in  measles,  259. 
in  pellagra,  430. 
Stools  in  cholera,  84,  86. 

in  dysentery,  amoebic,  199,  200, 

202  ;    bacillary,  195. 
in  enteric  fever,  15. 
in  pellagra,  428. 
in  relapsing  fever,  98. 
Subconjunctival  haemorrhages  in  small- 
pox, 289,  290. 
Subperiosteal  abscess  in  glanders,  147, 

150. 
Subsultus  tendinvmi  in  cholera,  86. 
'    in  plague,  73. 
in  smallpox,  288. 
in  typhus,  324. 
in  yellow  fever,  381 
Suffolk  epidemic  of  plague  in  1910,  77. 

Suicidal  tendengy  after  influenza,  161. 


Sweating  in  ama-bic  dysentery,  201. 

in  anthrax,  138. 

in  Kala  Azar,  210. 

in  malaria,  106,  108,  109. 

in  pulmonary   tuberculosis, 
174. 

in  rolapHing  fever,  99. 

in  rheumatic  fever,  360. 

in  typhus,  327. 

in  yellow  fever,  381. 

stage  in  malaria,  100,  108. 
Synovitis  after  malaria,  1 15. 

after  relapsing  fever,  102. 

T. 

Tiiche  bleuAtre,  11. 

ccrcbrale,  12. 
Temperatiore,  3. 

in  anthrax,  138,  139. 

in  beriberi,  418. 

in  cerebro -spinal   meningitis,    127, 

128. 
in  chickenpox,  314,  315. 
in  cholera,  85,  86. 
in  diphtheria,  48,  49. 
in  dysentery,  amcsbic,  199  ; 

bacillary,  195. 
in  enteric  fever,   13,   14. 
in  German  measles,  275,  277. 
in  glanders,  147. 
in  influenza,  155,  156,  157. 
in  Kala  Azar,  208. 
in  malaria,    106,  108,  109. 
in  measles,  254. 
in  mvunps,  349. 
in  pellagra,  430,  431. 
in  plague,  73,  76. 
in    piilmonary    tuberculosis,    167, 

168,  169. 
in  relapsing  fever,  98. 
in  rheumatic  fever,  358,  361,  362. 
in  scarlet  fever,  220,  221,  223. 
in  smallpox,    283,   285,    287,    288, 

289. 
in  typhiis,  325,  327. 
in  whooping  cough,  396,  400. 
in  yellow  fever,  380,  381,  392. 
Temperatui'e  observation  in  piflmonary 

tuberculosis,  174,  178. 
Tenesmus  in  dysenterj^,  amcEbic,   199, 

200  ;   baciUary,  195. 
Tertian  malaria,  105  to  107. 
Tetany  in  measles,  259. 
Tests,  Agglutination,  Widal's  reaction 
in  enteric  fever,  27. 
in  t3T3hus,  335. 
in  eerebro-spinal  meningitis 
132. 


468 


Index 


Tests — continued. 

Calmette'sreaction  in  pulmonary 

tuberculosis,  175. 
Ehrlich's  diazo -reaction  in 

enteric  fever,  29. 
Mallein  in  glanders,  150. 
Tuberculin  in  pulmonary  tuber- 
culosis, 175. 
Von  Pirquet's  in  pulmonary 
tuberculosis,  175. 
Thrombosis,    arterial,  in  enteric  fever, 
21. 
of  femoral  vein  in  typhus, 

331. 
venous,        in       bacillary 

dysentery,  195. 
venous,  in  enteric  fever, 
21. 
Ticks  and  relapsing  fever,  103. 

Tinnitus  aurium  in  typhus,  322. 

Tongue  in  beriberi,  415. 

in  cholera,  86. 

in  bacillary  dysentery,  195. 

in  enteric  fever,  13. 

in  pellagra,  427,  428,  430. 

in  plagvie,  73. 

in  relapsing  fever,  98. 

in  rheumatic  fever,  358. 

in  scarlet  fever,  219,  220. 

in  typhxis,  323,  324. 

in  yellow  fever,  380. 
Tonsillitis,  chronic,  after  scarlet  fever, 
233. 
in  rheumatic  fever,  368. 
in  scarlet  fever,  232. 

Tonsils  in  scarlet  fever,  219,  222,  223. 

Tracheotomy  in  diphtheria,  53,  63  to  66 

Treatment  of  anthrax,  141. 
of  beriberi,  419. 
of  cerebro-spinal  meningitis 

132. 
of  chickenpox,  319. 
of  cholera,  88  to  92. 
of  diphtheria,  59  to  67. 
of  dysentery,  amoebic,  203  ; 

bacillary,  196. 
of  enteric  fever,  30. 
of  German  measles,  280. 
of  glanders,  151. 
of  influenza,  161  to  163. 
of  Kala  Azar,  213. 
of  malaria,  116,  to  120. 
of  measles,  262. 
of  mumps,  354. 
of  pellagra,  438. 
of  plague,  78. 


Treatment — continued.  ; 

of  pulmonary    tuberculosis, 

175  to   185. 
of  relapsing  fever,  102. 
of  rheumatic  fever,  371. 
of  scarlet  fever,  238  to  246. 
of  smallpox,  299. 
of  typhus,  337. 
of  whooping  cough,  404. 
of  yellow  fever,  385. 
Treatment  of  complications 
of  cholera,  91. 
of  diphtheria,  67  to  69. 
of  amoebic  dysenterj%  204. 
of  enteric  fever,  37  to  41. 
of  measles,  263  to  268. 
of  mumps,  355. 

of  piilmonary  tuberculosis,  185. 
of  rheumatic  fever,  375. 
of  scarlet  fever,  241. 
of  smallpox,  302. 
of  typhus,  341. 
of  whooping  cough,  407. 
Treatment  of  sequelae 

of  cerebro-spinal  meningitis,     134. 
of  malaria,  120,  121. 
of  measles,  268.  ■ 

Tuberculin  in  pulmonary  tuberculosis, 

181  to  183. 
Tuberculosis  after  whooping  cough,402 
laryngeal,  172,  186. 
of  bladder,  172,  185. 
of  gastro -intestinal  tract, 

172. 
of  kidneys,  172,  185. 
of  liver,  172. 
of  mouth,  172. 
of  spleen.  172. 
of  testicle,  172,  185. 
of  tongue,  172. 
Tuberculous  infection    after    measles, 
260. 
meningitis,  172. 
meningitis,  after  measles, 

260. 
pyosalpinx,  172,  185, 
Typhoid  carriers,  43. 
"  Typhoid  cases  "   of  relapsing  fever, 

100. 
"  Typhoid  spine,"  24,  25. 
Typhus,  321  to  346. 
Alcohol  in,  338. 
Breath  in,  323. 
Clinical  types  of,  323  to  328. 
Complications  of,  329. 
Convalescence  from  ,325,  332. 
Crisis  in,  324. 
Death  rate  in,  344. 


Index 


400 


Typhus — continvttd. 

Dolirium  in,  IJ2l},  :J24. 

Diagnosis  of,  W.il  to  Wil. 

Diot  in,  ;>42. 

Epidomiology  of,  ."M.l. 

Eyos  in,  324. 

Faoios  of,  323,  327. 

Fulminant  typo  of,  .327. 

Headacho  in,  322. 

Hiccough  in,  324. 

Homo  prophylaxis  in,  344. 

Hypnotics  in,  338. 

Incubation  period  of,  321. 

Infection  in,   343. 

Infectivity  of,  344. 

Invasion  of,  322. 

Mild  forms  of,  328. 

Odour  of,  326. 

Prognosis  oF,  328. 

Public    health    administration    of, 
345. 

Pulse  in,  323,  324,  32(>,  327. 

Rash  in,  321. 

Respiration  in,  323,  324. 

Rigor  in,  322. 

Second  attacks  of,  344. 

Sequelae  of,  332. 

Sevei'e  type  of,  327. 

Sleeplessness  in,  323. 

Sordes  in,  323. 

Stimulants  in,  340. 

Subsultus  tendinum  in,  324. 

Sweating  in,  327. 

Temperature  in,  325,  327. 

Tinnitus  aurium  in,  322. 

Tongue  in,  323,  324. 

Treatment -of ,  337. 

Treatment  of  complications,  of  341 

Ventilation  in,  337. 

Vomiting  in,  322. 
Typhvis  febricula,  328. 


U. 


Ulceration  of  colon  in  amoebic  dysen- 
tery,  199. 
United  States  of  America,  pellagra  in, 

432. 
Urjemia  in  relapsing  fever,  100. 
in  scarlet  fever,  230. 
in  typhus,  331. 
Urine  in  beriberi,  415,  417. 
in  cholera,  85. 
in  malaria,  107. 
in  pellagra,  430. 
in  plagt;e,  73. 
in  relapsing  fever,  98. 
in  rheumatic  fever,  360. 


Urine — conlin'/ed. 

in  scarlet  fovor,  230. 
in  smallpox,  289. 
in  whof)f)ing  cough,  402. 
in  yelhnv  fovor,  .381. 
rotr;ntio))  f)f,  in  cholera,  85. 
in  plague,  73. 
,  in  relapsing  fever, 

1  r)0. 
ill  scarlet  fovf,'i',24.5 
Urticai'ia  after  malari;i,   I  15. 


V. 


Vaccination,  304,  306,  307  to  :JI2. 
generalised  vaccinia,  .31  I. 
number  of  inarks,  311. 
insusceptibility  to,  312. 
Vaccine,  Haffkine's,  in  cholera,  96. 
Vaccine  therapy 

in  enteric  fever,  41. 
in  pulmonary  tuberculosis,   180. 
Vaginitis  in  measles,  259. 
Valvular  disease  of  heart  after  scarlet 

fever,  233. 
Variola  vera.     See  Smallpox,  286. 
Varioloid.     ^S'ee  Smallpox,  290. 
Ventilation  in  typhus,  337. 
Vertigo    in   cerebro-spinal    meningitis, 
126. 
in  pellagra,  427,  428,  430. 
Vibrio   Cholera,  84. 

Deneke,  87. 
Vomiting  in  anthrax,  139. 

in  cerebro-siDinal   meningitis, 

126,  128. 
in  cholera,  85,  90. 
in  diphtheria,  57. 
in  influenza,  154,   156. 
in  malaria,  106,  109. 
in  plague,  73. 

in  relapsing  fever,  98,   100. 
in  scarlet  fever,   219,   221. 
in  smallpox,  283. 
in  typhus,  322. 
in  whooping  cough,  397,  401. 
in  yellow  fever,   381,   382. 
Vulvitis,  purulent,  in  measles,  259. 


W. 


Water-borne  epidemics  of  cholera,  92, 

93. 
Water  supply  in  amoebic  dysentery,  207 
Wet  beriberi,  417. 
Whooping-cough,  395  to  413. 

Age  incidence  of,  411. 

Alcohol  in.  408. 


II 


470 


Index 


\\'hoiipiiig-coiigh — continunl. 
Bacteriologv  of   410. 
Blood  in,  403. 
-     Blood  in,  examination  of,  403. 
Brouchial  catarrh  in.  390,  3!ti). 
Catarrhal  symptoms  in,  395. 
Clinical  types  of,  395  to  399. 
Complications  of,  399  to  402. 
Convulsions  in,  400. 
Cough  in,  395,  396,  397,  398. 
Death  rate  in,  411. 
Diagnosis  of,  403. 
Diarrhoea  in,  401. 
Diet  in,  409. 

Drug  treatment  of,  407. 
Epidemiology  of,  410. 
Glands  in,  403. 
Home  prophylaxis  in,  412. 
Incubation  period  of,  395. 
Infection  in,  411. 
Infectivity  of,  411. 
Laryngitis  in,  396,  400. 
Nervous  irritability  in,  402. 
Open-air  treatment  of,  405,  406. 
Paroxysm  in,  397. 
Paroxysmal  stage  of,  397. 
Public    health    administration    of, 

412. 
Praise  in,  398. 
Rectal  feeding  in,  410. 
Seqxiela?  of,  402. 
Temperature  in,  396,  400. 
Treatment  of,  404. 
Treatment  of  complications  of,  407 
Urine  in,  402. 
Vomiting  in,  397,  401. 
Warning  of  paroxysm  in,  398. 

X. 

X-rays  in  puhnonary  tuberculosis,  175- 


Yellow  fever,  379  to  394. 
Alcohol  in,  386. 


Yellow  fever — contimicl. 
Alkalis  in.  386. 
Bacteriology  of,  385,  389. 
Blood  pressure  in,  383. 
Clinical  types  of,  380. 
Complications  of,  383. 
Death  rate  in,  391. 
Deliriumi  in,  381. 
Diagnosis  of,  383. 
Diet  in,  387. 
Epidemiology  of,  387. 
Eyes  in,  380,"  381. 
Facies  of,  380,  381. 
Gastric  symptoms  in,  380,  381,  382 
Grave  forms  of,  382. 
Haemorrhages  in,  381. 
Headache  in,  380. 
Hiccough  in,  381. 
Immunity  from,  389. 
Incubation  period  of,  379. 
Infection  in,  389. 
Infectivity  of,  391. 
Invasion  of,  380. 
Period  of  calm  in,  381. 
Period  of  reaction  in,  381. 
Petechia?  in,  381. 
Prophylaxis  in,  392. 
Pulse  in,  380,  383. 
Piirgatives  in,  385. 
Rash  in,  379. 
Relapses  in,  392. 
ResjDiration  in,  380. 
Second  attacks  of,  392. 
Skin  in,  381. 

Subsultus  tendinvim  in,  381. 
Sweats  in,  381. 

Temperatm-e  in,  380,  381.  392. 
Tongue  in,  380. 
Treatment  of,  385. 
Urine  in,  381. 
Vomiting  in,  381,  3.82. 


Z. 


Zeist  or  maize  theory  of  pellagra,  434. 


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